Policy & Financial Agreement Form In order to ensure the safety of your child during his/her therapy session, it is imperative that an adult be present in your household at all times. While it is not mandatory that you, as the parent/caregiver, are present during the actual session, it is very beneficial. ** Please initial next to ALL bullet points regardless of whether or not it applies to you at this time indicating that you have read and understand the policies of ASTS.** Child Name*Parent Name** Clients are responsible for any and all charges incurred resulting from treatment provided by Advantage Speech Therapy Services, Inc. (ASTS). As a courtesy to you, ASTS will gladly call your insurance carrier to identify your current benefit coverage. However, please understand that insurance verification IS NOT a guarantee of payment by your insurance carrier. We can only use the information we obtain as an estimated guideline. The actual payment of your claim may take 4-6 weeks or longer, but most insurance carriers pay in 2-4 weeks. ASTS will also file claims on your behalf to your insurance carrier up to two times per appointment. However, if charges billed to your insurance carrier are not paid in a timely manner (due to circumstances beyond our control) it will then become your responsibility to pay your bill and resolve the outstanding issue with your insurance company and receive reimbursement from them. While we will verify your insurance we also ask that YOU take an active role in your insurance by contacting your carrier and verifying your coverage for speech therapy services. By taking an active role you will be better equipped to aid in any appeals processes that may arise, to know what additional information may be required by you or your primary care physician in order to have such services considered for reimbursement by your insurance carrier, and be better able to understand your Explanation of Benefits (EOBS) when it arrives as it pertains to any invoice you may receive from us for payment. It is your responsibility to complete all forms required by ASTS, provide correct insurance billing information PRIOR to your first session, and also to provide a copy of your insurance card(s) (front & back) as well as driver’s license at the time of your first session. Initial:** Your insurance company may also require a current prescription, diagnosis, “Letter of Medical Necessity”, pre-authorization or physical notes for speech therapy services which come directly from your primary care physician. If your primary physician gives you a referral, RX or written diagnosis please let your therapist know IMMEDIATELY. ASTS does not require the parents to be the first line of defense in obtaining this information. ASTS will do all we can to obtain this information from your primary physician should your insurance company require it, but ultimately we may require your assistance. Non-compliance by the primary care physician or yourself may result in services not being reimbursed by your insurance company. Any required information regarding treatment, treatment plan, treatment goals, progress notes or evaluations will be handled by Advantage Speech Therapy Services. Initial:** Once an EOB (Explanation of Benefits) and payment for services has been received from your insurance company, we will bill your secondary source of insurance for consideration of payment if one has been established. Otherwise you will receive an invoice for payment based on any deductibles, co-insurance, co-payments, non-covered services or cost participation amounts as a result of services rendered by ASTS. Since it may take 4-6 weeks to receive an EOB from your insurance carrier and you may have accumulated more than one months worth of services, we ask that you please plan ahead as you will be expected to pay the balance on any and ALL of the invoices within a two week period of the dated invoice. initial*Advantage Speech Therapy will process patient charges as follows:* SELF PAY / NO INSURANCE – Payment is due in full at the time services are rendered, unless other arrangements have been made and approved by ASTS. Charges for clients with SELF PAY/NO INSURANCE will be charged a flat cash rate of $85 per therapy session or $90 if paying by credit card and a flat cash rate of $300 for a full evaluation or $315 if paying with credit (rates subject to change). Initial:** Client must notify ASTS immediately that that they are submitting a claim to insurance independent of ASTS’ Billing services. If private pay was original form of payment, ASTS needs to be notified within the first 180 days of any changes to their payment plan in order for any potential payment reimbursement to occur as a result of filing to insurance, if applicable. Initial:** MEDICAID / CMO – ASTS is a participating provider of straight Medicaid and some of the CMOs (subject to change). If Medicaid is your primary insurance, no other action should be necessary. If you have a commercial insurance plan that is primary and Medicaid as your secondary source, ASTS will bill your primary insurance first and Medicaid second. If for any reason primary insurance or Medicaid does not reimburse for any services billed, you will be responsible for reimbursement of denied services at the Medicaid rate. Please note that ASTS is not considered in network with ANY HMO plan and therefore non-payment by primary insurance because of out of network status will NOT be covered by Medicaid. Initial:** COMMERCIAL INSURANCE – IN NETWORK/OUT OF NETWORK As a courtesy to you, we will verify your insurance and file your primary, secondary and tertiary insurance up to two (2) times per visit. After that it becomes your responsibility to make payment to ASTS for services rendered and to resolve the outstanding issue with your insurance carrier and receive reimbursement from them. If we are IN NETWORK with your insurance carrier you are responsible for the FULL balance on your account, such as, but not limited to, deductibles, co-pay, co-insurance and any non-covered services. As a courtesy to you, any NON-COVERED services such as, but not limited to, travel will be billed to you at a reduced rate of service. Travel at this time (which is subject to change without notice) is being billed at a reduced rate of $10 when not covered by insurance. If we are OUT OF NETWORK with your insurance carrier you will be charged a flat rate of $85 (cash rate) or $90 (if paying by credit card) per session while your deductible is being satisfied. Once your deductible has been satisfied you will be responsible for the difference of what insurance has paid and the $85 flat rate. As a courtesy to you, any NON-COVERED services such as, but not limited to, travel, will be billed to you at a reduced rate of service. Travel at this time (which is subject to change without notice) is being billed at a reduced rate of $10 when not covered by insurance. Initial:** HMO PLANS – ASTS is NOT in network with ANY HMO. If you are covered by an HMO you may still have out of network benefits available. If that is the case you will be billed in FULL for balances on your account, such as, but not limited to, deductibles, co-pay, co-insurance, any non-covered services and if applicable. If your HMO has no out of network benefits available you will be subject to the out of pocket cash rate of $85 per session or $90 if paying by credit card. Initial:** PATIENT BILLING – Once the Explanation of Benefits and/or payments arrive from your insurance carrier, ASTS will then bill your secondary source of insurance if one has been established. Since therapy is usually ongoing, we try and wait for ALL Explanations of Benefits and payments to be received for each month services are rendered rather than invoicing you on a weekly basis. Because of this, your billing cycle may not begin immediately or you may receive more than one month’s invoice at one time. We ask you to please plan accordingly so that you are able to pay your invoice by the due date specified. Invoices are mailed monthly for ANY out of pocket expenses. Payments not paid IN FULL within 14 days of invoice will incur a minimum charge of $10 or 10% (of your total bill- whichever is higher). Late fees will continue to accrue an additional 10% of the total invoice each subsequent week the invoice is not paid in full. All checks should be paid to the order of Advantage Speech Therapy Services, Inc. You have the option to pay by credit card/debit card but will incur a transaction fee. This transaction fee will need to be added to your total bill BEFORE submitting payment to ASTS. If this fee is not added at the time of the transaction it will be added to your next bill. Initial:** CANCELLATION OF SERVICES POLICY – As part of your financial responsibility we are advising you that ASTS INC. reserves the right to charge a fee for any appointment that is not kept or not cancelled by giving 24 hours advanced notice. Currently there is an out of pocket fee of 50% of your total insurance rate for a typical treatment session or a minimum of $55 (effective January 2008), which is subject to change without notice. Unforeseen circumstances are anticipated and will be dealt with on a case by case basis. ASTS, INC has a 3 strike rule. If you are unavailable for a scheduled appointment 3 times without calling to cancel 24 hours in advance of your appointment, ASTS retains the right to discontinue elective treatment and to terminate services immediately. ASTS kindly requests that you offer advanced notification so that your therapist is aware of your need to reschedule. Additionally, at the discretion of ASTS, excessive cancellations within a given month may result in a termination of the given contract. Furthermore, if you plan to dismiss your child from therapy, a 2 week notification is REQUIRED unless otherwise agreed upon. Consequently, if you choose to discontinue treatment you are still responsible for paying for all services that were provided prior to your decision to discontinue. Initial:** It is ASTS’ responsibility and commitment to each client to keep the set # of sessions each month. Therefore, when an appointment is canceled, the understanding is that it is made up to keep to the set # of sessions we have committed to. Initial:** Missing your scheduled appointment hurts 3 people: 1) Your child’s potential due to lack of consistency with appointments, 2) Taking up the appointment that another client could have benefited from, and 3) Your therapist now has a gap in her schedule. Initial:*By signing this form you are agreeing to the following:* You understand that unresolved financial disputes for non-payment of fees for services rendered could result in the discontinuation of services, referral to another provider as necessary, an assignment of collection responsibility for this account to a professional Collection Agency or submission to the County Magistrate Court for small claims. Furthermore, you agree that if it should become necessary for ASTS INC. to forward your account to a collection agency or to the state court, you will be responsible for the costs of collection and filing fees in addition to ASTS’s services including late fees. Initial:** You also agree to authorize ASTS INC. to receive or release any medical information to your insurance company, physician(s), or any other parties that may be involved in the child(s) care. Initial:** You authorize insurance payments be made directly to Advantage Speech Therapy Services Inc., for services rendered. However, if your insurance company sends payment for services directly to you, you will send payment of that amount to ASTS with a copy of your EOB in order to ensure proper credit to your account. Initial:** You will make ASTS aware of any changes in your payment sources in order to ensure proper billing. Initial:** You accept that travel is being billed at a reduced rate of $10 when not covered by insurance (where applicable). Initial:** Any check returned on an account will be charged a $30 fee. Initial:** A transaction fee will be added to your total bill if using a credit card (when applicable). Initial:** You will inform ASTS if for some reason insurance coverage is terminated or the guarantor will be responsible for payment of services. Initial:** If your child is also receiving services through a school system we MUST have a copy of your child's IEP. It is mandatory that each year after the IEP is updated it is understood that ASTS must be given a copy of the updated IEP. Initial:** If your child is covered by Amerigroup as their insurance carrier we MUST have a copy of a hearing test performed by an audiologist prior to or at the time of the evaluation. This is a requirement of Amerigroup for us to obtain an authorization for therapy. Initial:** I, parent/legal guardian for the child, have been made aware of the billing policies and procedures for Advantage Speech Therapy Services, Inc and agree to them effective immediately. Parent/legal Guardian Signature*CAPTCHANameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms. Advantage Speech Therapy Services, Inc reserves the right to make changes to the above policies and procedures at any time. If you have any questions on your billing statement or invoice please call Robyn Drothler (owner, SLP) @ 404-784-1252.