I understand the need for courtesy to give my therapist at least 2 business days notice if I need to cancel my appointment and agree to pay a $25 cancellation fee if I fail to give sufficient notice. A 'no-show' may result in termination of therapy.

I understand Medicare will pay 80% of charges and my secondary insurance will be billed the remaining 20%, but I assume responsibility for any co-payment. For other insurances, I agree to pay in full any co-payment, coinsurance, or deductible due on the day of my appointment.

If my insurance denies payment, I understand that I am responsible for payment of services.

When privately paying and requesting services not covered by insurance, I understand that my insurance will not be billed and that I am responsible for a private pay rate of $120 per visit, payable upon receipt of billing statement. 

Read about your rights as a patient​

I have read and understand my rights as a patient