Occupational Therapy Financial Policy & Payment Agreement

Patient Information

Name: ___________________________ Date of Birth: _______________ Responsible Party (if minor): ____________________________________

Financial Agreement

1. Insurance Coverage

• I understand that I am responsible for knowing my insurance benefits and coverage
• I agree to provide current and accurate insurance information
• I understand that verification of benefits is not a guarantee of payment
• I acknowledge that some services may not be covered by my insurance plan

2. Payment Responsibility

• I understand that I am responsible for all charges not covered by insurance
• Copayments are due at the time of service
• Deductibles and coinsurance amounts will be billed after insurance processing
• Self-pay rates are available for patients without insurance coverage

3. Cancellation Policy

• 24-hour notice is required for appointment cancellations
• A fee of $_____ will be charged for late cancellations or no-shows
• Repeated cancellations may result in discharge from therapy services

4. Payment Methods

• We accept cash, personal checks, and major credit cards
• Payment plans are available upon request and approval
• Returned checks will incur a $_____ service fee

5. Outstanding Balances

• Accounts over 90 days past due may be referred to collections
• Additional fees may apply to accounts sent to collections
• Treatment may be suspended until payment arrangements are made

Authorization

I have read and understand the financial policy above. I agree to comply with these terms and accept financial responsibility for services rendered.

Signature: _________________________ Date: ________________

Print Name: ________________________ Relationship to Patient: ________________