Practice Policy Agreement 2022

Thank you for choosing OCSS as your therapy provider. We are committed to providing quality therapy to all our patients. The following is a statement of our financial policy which we require you read and agree to prior to any treatment (or further treatment).

• Please know that payment of your bill is considered part of your treatment. Any patient responsibility/fee are payable when services are rendered. We accept, check, and credit card.

• We verify benefits as a courtesy to our patients and we are a no time to be held responsible if incorrect information has been obtained. Please remember that the information we get from your carrier is only an estimate, and we cannot be sure of the exact amount until we submit a claim and receive an Explanation of Benefits. Your insurance company will process your claims as in or out of network according to your insurance policy.

• It is your responsibility to provide current and accurate insurance information, including any updates or changes to coverage. Should you fail to provide this information, you will be financially responsible.

• If we have a contract with your insurance company we will bill your insurance company first, less any copayment(s) or deductible (s) and then bill you for any amount determined to be your responsibility. This process generally takes 45-60 days from the time the claim is received by the insurance company.

• If we do not contract with your insurance company, you will be expected to pay for all services rendered prior to your child’s therapy appointment. We will bill your insurance company and reimburse you any funds you made to OCSS less co-pays/deductibles.

• Please understand some insurance coverages have Out-Of-Network benefits that have co- insurance charges, higher co-payments, and limited annual benefits. Please understand that Out- Of-Network rates can be higher than In-Network.

• I understand I may be asked to pay for In-Network therapy sessions, my insurance company will be contacted for an official decision on payment and if my insurance carrier does pay, OCSS will refund any payments made, less co-pays/deductibles.

• I understand that my insurance company may not pay for ANY of the CPT codes OCSS bills and my insurance company can deny these codes for ANY reason.

• I understand that after three cancellations by the patient, my child will be removed from
the schedule.

• Practice policy for plans excluding Kaiser Permanente allow for 30-minute treatment sessions. I understand that clinical hours are as follows: 30-minute visits are 25-minutes direct therapy, and 60-minute sessions are 50 minutes direct therapy. This allows for documentation, training, and sanitation.

• I understand I must pick up my child on time.

(Please read and only initial what applies to you)
*Insurance patients
*Self Pay patients:

I have read the financial policies above, and my signature below serves as acknowledgement of a understanding of my financial responsibility. I understand that if my insurance company denies previously approved coverage and/or payment for these services provided to my child, I assume financial responsibility and will pay all such charges in full.

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