Speech Therapy Services Financial Agreement

Patient Information

Name: ___________________________
Date of Birth: //____
Responsible Party (if different): ___________________________

Financial Responsibility Agreement

1. Payment Terms

   • Payment is due at the time of service
   • We accept cash, checks, and major credit cards
   • Co-payments must be paid at check-in
   • Outstanding balances must be paid before new appointments

2. Insurance Coverage

   • I understand that I am responsible for:
     • Verifying insurance coverage
     • Obtaining necessary referrals
     • Paying any non-covered services
     • Meeting deductible requirements
   • Insurance authorization is not a guarantee of payment

3. Missed Appointments

   • 24-hour notice is required for cancellations
   • Late cancellations/no-shows will incur a fee of $___
   • Multiple missed appointments may result in discharge

4. Payment Plans

   • Available upon request for qualifying patients
   • Must be arranged prior to treatment
   • Requires signed payment plan agreement

Acknowledgment

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

Signature: ___________________________
Date: //____

Practice Representative: ___________________________
Date: //____