Financial Agreement:

I understand that there is no guarantee of payment from any insurance company or other payer. I agree to pay all charges for the services provided by Valley Kids Therapy which are not paid by my health insurance or other payer. All charges are due and payable when I receive the bill. If payment is not made within 90 days from the date the bill was sent from Valley Kids Therapy, I understand that a delinquent charge of interest rate of 18% may be added to my bill. I agree to pay all reasonable legal expenses necessary for the collection of any debt. I understand that any credit or refund that I may be owed will be forwarded to the address on file with Valley Kids Therapy. I understand that I am responsible for a $25.00 returned check fee in addition to any other associated bank charges. I authorize that payment of any insurance (including auto insurance and healthcare insurance) benefits for health care services or goods may be made directly to Valley Kids Therapy.

Insurance Changes:

I accept responsibility to notify Valley Kids Therapy of any changes to my insurance plan, benefits, and/ or coverage. I acknowledge that I am responsible for all charges not covered by my insurance plan.

Pre-authorization Requirements:

I accept the responsibility to obtain all referrals or pre-authorizations and to comply with all requirements of any insurance or medical coverage plan upon which I am relying for medical coverage of Valley Kids Therapy charges.

No Show/Cancellation without 48-hour notice:

I understand that 48-hour notice is required for canceling an appointment. Families receive text and email reminders 24 hours in advance of appointments. Please be sure we have accurate contact information. I understand that after 3 late arrivals or cancelations, my scheduled appointment times will be forfeited to another patient and I will be placed back on the wait list. Late cancellations (day prior to appointment, within 24 hours of appointment time) will be charged a $50.00 missed appointment fee. No-Shows and SAME DAY CANCELLATIONS will be charged a $75.00 missed appointment fee. Patients have the option of converting to a telehealth appointment to avoid Late Cancel/No Show fees. If we are able to fill the missed appointment time with another patient, we will waive the cancellation fee.

Credit Card Required on File:

All patients are required to have a credit card on file with Valley Kids Therapy prior to their first appointment. This card will automatically be charged any balances of $100 or less. Patients with a balance greater than $100 will automatically be enrolled in our payment plan according to the following procedure:

• Balances of $101 to $200: $40 per month
• Balances of $201 to $350: $50 per month
• Balances over $350: $75 per month

Families have the option to increase monthly payment amounts according to their preferences. Current patients will also need to provide a credit card and will be charged/enrolled in the payment plan according to the same procedure prior to their next scheduled appointment with Valley Kids Therapy.

I acknowledge that:

• I acknowledge that I have read this form and understand its contents.
• I am the patient, or person duly authorized either by the patient or otherwise, to sign this agreement, consent to, and accept its terms.
• I am responsible for the payment, co-payment and/or deductible that are due at the time of service.