Parent Policy | OC Speech Services

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 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)

By Initialing here, I am responsible for signing in (the patient/child) via QR Code found at the entrance doors in the front and back of Orange County Speech Services.

By Initialing here, I understand OCSS is a contracted provider for Easterseals. We are seen through authorizations sent by Easterseals. I understand I am responsible for any copays due at the time of our appointment, if copays are not collected, we will bill you for your copays.

By Initialing here, I understand that when I am given back-to-back service appointments, and one appointment is cancelled by our staff, I will need to keep the remaining service appointment.

I understand OCSS works very hard to get us back-to-back appointments. For Continuity of care, we encourage you to keep your second and/or third appointment. It will now be a new policy that (if only one appointment is cancelled, and you CHOSE to cancel your second appointment, it will now be considered a cancel by you and counted against one of your three (3) cancels.

*Insurance patients

By initialing here, I elect to receive services from the first visit until termination of services. If my insurance denies services I may be asked to pay in full at any time. OCSS will re-bill my insurance for a final decision on payment. I understand I will receive an EOB by my insurance company (by mail or electronic form) containing benefits determinations.

I understand I can appeal any denial by following the directions for an insured member of my plan. If an appeal is paid, I understand I will be refunded by OCSS less any co-payments/deductibles.

*Self Pay patients:

By initialing here, I am requesting additional non-covered services that won’t be billed to my insurance. I am responsible for this additional payment and will pay per visit.

By initialing here, I am asking OCSS NOT to bill my insurance company. My insurance will not be billed and I will make all payments at the time of service. (CASH PATIENTS ONLY)

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.

Contact Us:

(714) 916-0641

elizabeth@ocspeechservices.com

Practice Policy Agreement 2022