I understand the need for courtesy to give my therapist at least 2 business days notice if I need to cancel my appointment and agree to pay a $25 cancellation fee if I fail to give sufficient notice. A 'no-show' may result in termination of therapy

 

I understand Medicare will pay 80% of charges and my secondary insurance will be billed the remaining 20%, but I assume responsibility for any co-pay. If I have Blue Cross, Harvard Pilgrim, etc., I agree to pay the co-pay and/or deductible. My co-pay will be collected on the day of appointment.

 

If my insurance denies payment, I understand that I am responsible for payment of services.

 

When privately paying and requesting services not covered by insurance, I understand that my insurance will not be billed and that I am responsible for a private pay rate of $100 per visit, payable upon receipt of billing statement.

 

I have read and understand my rights as a patient (see opposite side of this page).