Patient Service Agreement and Payment Policy Web Site Agreement of Services & Payment Policy Please review the following service agreement and payment policy for Occupational Therapy, Speech Therapy, and Applied Behavior Analysis Services. Please ask any questions you may have and sign in the space provided indicating your understanding of this Agreement. 1. Insurance We participate in many insurance plans, including the following: Blue Cross Blue Shield, Sanford Health Plan, Medicaid, and Tricare. If you are not insured by a plan we do business with, payment in full is expected at each visit. If you are insured by a plan we do business with, payment in full for each visit may be required up front until we can verify insurance coverage. We will complete a brief verification of benefits prior to your first visit to ensure the services are a covered benefit under your plan, as well as file insurance claims to your primary and/or secondary carriers for your convenience. However, knowing your insurance benefits and limitations is your responsibility. Please contact your insurance company with any questions you may have regarding your coverage for Occupational and Speech Therapy. See Disclaimer at the end of the Agreement. 2. Co-payments and Deductibles We request that co-payments and deductibles be paid at the time of service. This arrangement is part of your contract with your insurance company. We require that you keep a credit card on file for weekly co-pays, deductibles, and/or weekly therapy payments. By signing this Agreement, you agree to allow Wonderment Therapies PLLC to charge your card co-pays, co-insurance, and deductibles at the end of each month to collect payment for services rendered. 3. Private Pay In order to receive services on a private pay basis, all service fees must be paid before service is provided. 4. Non-Covered Services Please be aware that some, or perhaps all, of the services you receive may not be covered by your insurance carrier(s). Insurance carriers and their policies differ widely in terms of what Diagnoses and Procedures they will cover. We will work with you to help determine what your policy will cover but it is your responsibility to ensure that your policy will cover the specific Diagnosis provided for your child. Therapists can attend 1 IEP or other patient centered meeting per year. Meetings are not a billed service as they are not covered by insurance. 5. Proof of Insurance All patients must complete our Patient Information form before being seen by a therapist. This form is found on our website, www.wondermenttherapies.com. We must also obtain a copy of your current valid insurance card to provide proof of insurance. If you fail to provide us with the correct insurance information in a timely manner, you may be responsible for the balance of a claim. If you do not notify Wonderment Therapies PLLC of a change or cancelation in insurance, you may be responsible for the balance of the claim if not paid by the insurance provider. 6. Claims Submission We will submit your claims and assist you in any way we reasonably can to help get your claims paid. Your insurance company may need you to supply certain information directly. It is your ultimate responsibility to comply with their request. Please be aware that the balance of your claim is your responsibility whether or not your insurance company pays your claim. Your insurance benefit is a contract between you and your insurance company; we are not a party to that contract. 7. Termination of Insurance In the event your insurance is terminated for any reason and we are not able to collect payment from your insurance provider, you will be responsible for payment in full for said unpaid claims. 8. Coverage Changes If your insurance changes, please notify us before your next visit so that we can make the appropriate changes to help you receive your maximum benefits. In the event you do not notify our office in a timely manner and your insurance has expired or becomes inactive for any reason, you will be responsible for any unpaid claims. 9. Nonpayment If your account is over 60 days past due, you will receive a letter stating that you have 30 days to pay your account in full. Partial payments will not be accepted unless arrangements are made in advance with our office. If your account total reaches $500.00 with no attempt to pay, we may decrease frequency of therapy until the account is in good standing. Please be aware that if your balance remains unpaid, we may refer your account to a collection agency and your child will be discharged from services. If you wish to return to services, your account must be in good standing. 10. Therapy Services To request an estimate of cost, please contact our billing/office staff. If you are unable to pay your bill in full, please contact billing/office staff to set up a payment plan. 11. Termination of Therapy Wonderment Therapies PLLC reserves the right to suspend and/or terminate therapy at our discretion. Reasons for termination include, but are not limited to, untimely payment of fees, failure to comply with treatment recommendations, conflicts of interest, failure to participate in therapy, the patient's needs are outside of the therapist's scope of competence or practice, or the patient is not making adequate progress in therapy. The patient has the right to terminate therapy at his/her discretion. Upon either party's decision to terminate therapy, the therapist will recommend that the patient participate in at least one, or possibly more, termination sessions. These sessions are intended to facilitate a positive termination experience and give both parties an opportunity to reflect on the work that has been done. If determined to be medically necessary, the therapist will also attempt to ensure a smooth transition to another therapist by offering referrals to the patient. 12. Release of Information By signing this Agreement, you agree to allow Wonderment Therapies PLLC Therapist(s) to discuss concerns, treatment, diagnosis and test results with collaborating health professional(s) (i.e. your child’s Pediatrician) that may provide beneficial information to collaborate with and to assist your child’s Therapist in providing Therapy to your child. If you would like Wonderment Therapies PLLC Therapist(s) to collaborate with other professionals such as other therapists, teachers, etc., a signed Release of Information will be completed. 13. Supervision of Therapy Therapy provided to Wonderment Therapies PLLC patients is supervised by Jenna Weisz, MS, OTR/L; MS, BCBA, LBA, Clinical Director. Clinical Progress Notes and Evaluation Reports may be reviewed by Jenna Weisz on a case by case basis. In the event you would like to discuss your child’s services, Jenna may be contacted by email at jenna.weisz@wondermenttherapies.com. 14. Missed Appointments/Attendance Policy Patients must retain at least a 70% attendance rate per month for continuation of services. Late cancellations (appointments cancelled less than 12 hours prior) and no-show appointments will be charged $50. These charges will be your responsibility and billed directly to you. Please help us to serve you better by keeping your scheduled appointments, when possible. If it is deemed appropriate, telehealth sessions may be offered in place of your in-person visit. Although telehealth visits may not be your ideal service delivery method, telehealth is beneficial in ways such as helping caregivers to better understand what is happening in therapy sessions. Our practice is committed to providing your child with high quality therapeutic services to achieve your reasonable goals and objectives for your child. Insurance Disclaimer: Please understand the insurance information provided to you is not a guarantee of payment. Information provided is a courtesy and has been supplied to our office from your Insurance Carrier as of the date the information has been relayed; However, your insurance policy is a contract between you and your carrier and specific information about your coverage should be obtained directly from your Insurance Provider. This information is collected by our office based upon the following inquiries: • Is Occupational Therapy and/or Speech Therapy a payable benefit under this plan? • Is the child’s diagnosis code(s) a covered code? • Do services fall under Habilitative or Rehabilitative on this policy? • How many sessions are allowed per year? • Are these sessions combined with any other therapies in the maximum number of sessions per year? • What is the plan co-pay and deductible? • What amount of the deductible is currently met? • Is authorization required for Occupational Therapy and/or Speech Therapy? *Answers and benefit information provided by your Insurance Carrier is relayed to you. PLEASE be aware – this is not a guarantee of payment and policies are subject to change. I have read and understand all pages of the Agreement of Services and Payment Policy, including the Disclaimer and agree to abide by its guidelines. Further, I may request a copy of said Agreement to retain for my records. I Give Consent to Wonderment Therapies PLLC to submit claims and supportive documentation to prove medical necessity to my insurance carrier. Type of Payment for Service * Insurance Private Pay First Name Last Name Email Address Electronic Caregiver Signature * Date *
