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As the parent or legal guardian of a child receiving services at 901 Therapy, I understand and agree that I am financially responsible for all services provided. This includes any charges not covered by insurance, such as co-pays, deductibles, co-insurance, and services deemed non-covered or denied by the insurance carrier.

Payment is expected at the time of service unless other arrangements have been made in advance. I acknowledge that outstanding balances may result in interruption or suspension of services until the account is brought current. If payment is not received within a reasonable timeframe, the account may be referred to a collections agency.

I agree to promptly inform 901 Therapy of any changes to my contact information or payment method, and I authorize the practice to charge my preferred payment method on file for any balance due.

901 Therapy will submit claims to my child’s primary insurance provider as a courtesy. I understand that it is my responsibility to ensure my child has active insurance coverage and to notify 901 Therapy of any changes in coverage, benefits, or policy details.

While 901 Therapy may assist in verifying benefits, I acknowledge that benefit information provided by insurance companies is not a guarantee of payment. I am ultimately responsible for understanding my insurance plan, including requirements for referrals, authorizations, and limitations on covered services.

I understand that I am responsible for any portion of charges not paid by insurance, including co-pays, deductibles, and non-covered services. If my insurance provider denies a claim or fails to pay within a reasonable period, I agree to pay the remaining balance.

901 Therapy values each child’s therapy time and reserves dedicated appointment slots for consistent care. In order to best serve all families, we ask that any cancellations or rescheduling requests be made with at least 24 hours’ notice via phone, email, or through the client portal.

Late Cancellation Fee: A $35 fee will apply to appointments canceled with less than 24 hours’ notice.

No-Show Fee: A $50 fee will apply if you miss an appointment without notice or arrive more than 15 minutes late.

Fee Waiver: Each family is eligible for one waived fee every six months in the case of illness, emergencies, or unavoidable events. Please contact us as soon as possible to request a waiver.

Frequent Missed Appointments: Missing three or more appointments within a 30-day period may lead to a review of your child’s therapy schedule or loss of their reserved therapy slot.

By signing below, I acknowledge that I have read and understand these policies and agree to comply with them to support the continuity of care for my child.