If you must cancel an appointment that you have scheduled, please call immediately. Except under
emergency circumstances, all appointments cancelled with less than 24 hours notice will be subject
to a $35 service fee. In the event that you arrive late for your appointment, I will do my best to see
you, however the appointment may be shortened due to time constraints; the full session fee still
applies. Please note that most insurance companies will not reimburse for missed appointments and
you will remain responsible for these charges. Please do not bring any child to the clinic that does
not have an appointment with us (e.g., siblings), unless you have discussed this in advance.

Therapy is scheduled 30 minute intervals with therapy comprising all but the final 5- 10 minutes allowing time for the parent/therapist consultation, therapy documentation and infection control cleanup at the end of each session. If you require more consultation time please feel free to call and arrange an appointment to discuss the patient's needs.

Help and cooperation is required in order to maintain a healthy environment. A child must be
temperature-free for 24 hours before returning to therapy. If your child has vomiting and/or
diarrhea, he/she should not return to therapy until 24 hours have passed since the last episode of
the same.
Children will not be seen if any of the following is present:
 Too ill or uncomfortable to function in the therapy setting;
 Continual runny nose;
 Thick or discolored nasal discharge;
 Excessive sneezing or coughing and mucus-producing cough;
 An elevated temperature.

Patient is being seen through his/her Medicaid/Peachcare/Insuracane Plan.

I participate with some insurance companies, but not all. In the event that I do not accept your
insurance, I will be happy to provide you with the necessary paperwork to assist you in seeking
reimbursement for out-of-network provider services. Please also be advised that many health
insurance plans have limited coverage for speech-language pathology services. I recommend that
you contact your insurance company to discuss the limits of your coverage.

The person who completes the Party Responsible for Payment section is responsible for payment of
all services rendered. In most cases, payment is due at the time services are rendered unless you
have made other arrangements in advance. For children scheduled for individual therapy without a
parent present, payment should be made in advance or be sent with the child (services will not be
provided otherwise). Accounts more than 30 days overdue will be subject to a $20 late fee and 5%
interest charge. Accounts more than 60 days overdue will be sent to collection. For clients seeking
third-party reimbursement, please be aware that you are ultimately responsible for the payment of
services rendered. In the event that your insurance carrier denies payment (including recoupment)
or does not remit payment within 45 days, the client will be responsible for payment of all services
rendered. I may at times provide discounts or fee waivers for families with extenuating
circumstances; however, it is the client’s responsibility to ensur

I agree for ALL insurance and Medicaid/Peachcare payments to be made directly to this office. Such payments will be applied to the clients bill for services. All clients except Medicaid participants will be expected to pay the remainder of the bill as outlined above.

I understand and accept the terms of therapy as outlined above.