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Telespeech Therapy, Inc. Flushing Quail Rd., Suite 500Bakersfield, CA 93312661-393-4022 Office, 661-829-1948 FaxPayment PolicyThank you for choosing Telespeech Therapy for your speech-language pathology needs. This is an agreement between Telespeech Therapy and you for payment of services provided. By signing this agreement, you are agreeing to pay for all services provided to you or your family member. Please read the following information carefully.*A valid credit card must be kept on file for all clients of Telespeech Therapy. The credit card will be used in the event of late cancellations and for outstanding balances over 30 days past due. As a courtesy, Telespeech Therapy, will bill insurances that we are contracted with. Let the office know if your insurance changes.Check with your insurance company before your first visit to find out what speech and language services they will pay for.Find out what information the insurance company needs and bring it with you to your first appointment. You may need a note from your doctor, called a referral, or permission from the insurance company, called pre-authorization. Referrals and pre-authorizations do not guarantee that insurance will pay for services. Pay all co-pays, deductibles, and non-covered services at the time of your appointment. We will submit a claim to your insurance company.Co-pays and deductibles are due at the time of service. If your insurance will not pay for services, you will be responsible for paying the full amount.If your insurance company does not pay us within 30 days, you will be billed for the full amount. If you do not have insurance or are using an insurance that we are not contracted with:Payment is due at the time of service. We accept major credit cards. Upon request, we will provide you with a Superbill which you may chose to submit to a private payer to try to obtain reimbursement for the fees associated with the services provided by Telespeech Therapy. The submission of superbills is independent of Telespeech Therapy, Inc. and will not be facilitated by our staff. *By signing this you are acknowledging and agreeing to Telespeech Therapy’s Payment Policy. You are agreeing to keep a valid credit card on file with Telespeech Therapy, Inc. . You are further agreeing to and permitting Telespeech Therapy, Inc. to charge that credit card without you being present for fees associated with late cancellations and for outstanding balances over 30 days past due. FORMTEXT ?????Patient’s NameI agree to the payment policies outlined above. FORMTEXT ?????Patient or Parent/Guardian SignatureDate FORMTEXT ?????Relationship to Patient ................
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