Financial Responsibility:
You could have chosen any number of therapy clinics; we thank you for
choosing us!
Effective January 1, 2015: We are happy to assist you in obtaining the
maximum insurance benefits that your policy provides. As a courtesy to
our patients, we will file your insurance and send any required
supporting documentation.
-I agree to be responsible for payment of all services rendered on my
behalf or to my dependents.
-All accounts with NSF/returned checks will have a $35 per check fee
applied
I hereby authorize Moore Pediatric Therapy Services to bill my insurance
company for direct reimbursement of therapy services rendered to my
child. I agree to pay the unpaid balance within 30 days after receipt of
invoice from Moore Pediatric Therapy Services
* Please be aware that some and perhaps all of the services provided may
be “non-covered” services with your insurance company. Your insurance
policy is a contract between you and your insurance company. We are not
a party to that contract. In the event your insurance company denies
coverage, you will be responsible for payment of all charges. You may
choose to appeal the decision by your insurance company; however, we
require that you pay the balance of the account within 30 days of
receipt of invoice from Moore Pediatric Therapy Services.
I understand if I have an unpaid balance to Moore Pediatric Therapy
Services and do not make satisfactory payment arrangements, my account
may be placed with an external collection agency. I will be responsible
for reimbursement of any fees from the collection agency, including all
costs and expenses incurred collecting my account, and possibly
including reasonable attorney’s fees if so incurred during collection
efforts.
In order for Moore Pediatric Therapy Services or their designated
external collection agency to service my account, and where not
prohibited by applicable law, I agree that Moore Pediatric Therapy
Services and the designated external collection agency are authorized to
(i) contact me by telephone at the telephone number(s) I am providing,
including wireless telephone numbers, which could result in charges to
me, (ii) contact me by sending text messages (message and data rates may
apply) or emails, using any email address I provide and (iii) methods of
contact may include using pre-recorded/artificial voice message and/or
use of an automatic dialing device, as applicable.