Payment & Attendance Policy
Thank you for choosing our private practice to serve you. We are committed to providing you with the highest quality care. Please know that the timely payment of your bill is an integral part of our service and as such, this payment policy is an agreement between you and Emerald City Therapies for payment of services provided. By signing this policy, you are agreeing to pay for services provided to you or your family member. As a client of Emerald City Therapies you are required to carefully review and sign our payment policy.
Registration $35
Social Skills Workshop $35 per session
Please read the following information carefully:
All therapy fees (including session fees and/or co-pays, if applicable) prior to the first day of the Social Skills Workshop. We accept the following payment methods at this time: cash, check, debit, credit, and health savings accounts. Checks should be made payable to:
Melanie Reynolds, M.S., CCC-SLP
We will provide you with an invoice outlining the services rendered and the amount charged upon request.
I understand that I am responsible for all costs / fees that any third-party payer (ex. insurance company, private school, etc.) does not cover. In the event that a third-party payer source determines that rendered therapy services are “not covered” or otherwise denied, I will be responsible for all outstanding charges. I understand that I will be billed accordingly and will be responsible for immediate payment. I also understand that Emerald City Therapies will not become involved in disputes between you and your third-party source regarding uncovered charges or reasons for denial.
I understand that if fees are not paid in full, treatment sessions may be postponed or cancelled until payment is received.
I understand that all returned checks will be subject to a $_25_ returned check fee. Charges incurred and not paid after _60_ days may be turned over to a collection agency at the client’s expense. Overdue accounts may also be reported to a Credit Bureau.
I understand that I am responsible for all legal and collection fees, which Emerald City Therapies may incur if payment is not made in accordance with the terms and conditions herein.
I understand that refunds will be issued only in instances of overpayment. All refunds will be processed within __30__ days after the overpayment is discovered on the client’s bill or at the time the refund is requested.
I, understand that all cancellations require __24__ hours’ notice and that there will be a __$35__charge for any cancellations made less than _24_ hours. This charge is my sole responsibility and will not be covered by a third-party source.
Registration $35
Social Skills Workshop $35 per session
Please read the following information carefully:
All therapy fees (including session fees and/or co-pays, if applicable) prior to the first day of the Social Skills Workshop. We accept the following payment methods at this time: cash, check, debit, credit, and health savings accounts. Checks should be made payable to:
Melanie Reynolds, M.S., CCC-SLP
We will provide you with an invoice outlining the services rendered and the amount charged upon request.
I understand that I am responsible for all costs / fees that any third-party payer (ex. insurance company, private school, etc.) does not cover. In the event that a third-party payer source determines that rendered therapy services are “not covered” or otherwise denied, I will be responsible for all outstanding charges. I understand that I will be billed accordingly and will be responsible for immediate payment. I also understand that Emerald City Therapies will not become involved in disputes between you and your third-party source regarding uncovered charges or reasons for denial.
I understand that if fees are not paid in full, treatment sessions may be postponed or cancelled until payment is received.
I understand that all returned checks will be subject to a $_25_ returned check fee. Charges incurred and not paid after _60_ days may be turned over to a collection agency at the client’s expense. Overdue accounts may also be reported to a Credit Bureau.
I understand that I am responsible for all legal and collection fees, which Emerald City Therapies may incur if payment is not made in accordance with the terms and conditions herein.
I understand that refunds will be issued only in instances of overpayment. All refunds will be processed within __30__ days after the overpayment is discovered on the client’s bill or at the time the refund is requested.
I, understand that all cancellations require __24__ hours’ notice and that there will be a __$35__charge for any cancellations made less than _24_ hours. This charge is my sole responsibility and will not be covered by a third-party source.