Kitestring's Payment Information ONLY

Client's Name*

First NameLast Name

Client's sex (as stated on their insurance policy, if applicable).*

MaleFemalePrefer not to answer

Date of Birth*

Date

Please choose an invoice method:*

Mailed, full detail, paper invoicesPaperless, streamlined, email invoices (Our billing specialist will be available to answer any questions you may have about insurance or billing details).

Please identify your preferred payment method*

Bill insurancePrivate PayNot sure

Are you interested in auto-pay or having Kitestrings Pediatric Therapy keep payment information on file?*

NO, I do NOT wish to participate in auto-pay or have Kitestrings Pediatric Therapy keep payment information on file.YES, I would like to participate in auto-pay or have Kitestrings Pediatric Therapy keep payment information on file.Unsure

NOTICE:

If YES, Your first invoice will be emailed to you. To enroll in autopay, please pay your first bill with the credit card you would like to use for autopay, and be sure to select "Save my card on file." Kitestrings will then be able to run your card automatically and send you a mailed receipt monthly.

NOTICE:

Switch to autopay at anytime. Simply email info@kitestringstherapy.com a request, and we will email your next invoice to you. Then, to enroll in autopay, please pay the invoice with the credit card you would like to use for autopay, and be sure to select "Save my card on file." Kitestrings will then be able to run your card automatically and send you a mailed receipt monthly.

Please choose a payment method:*

Credit Card/ACH: pay monthly online at www.kitestringstherapy.com after receiving your invoiceCheck

Payments are due within 15 days of the date of the invoice, mailed to you monthly.
Therapy will be placed on hold if a payment is more than 60 days late.
Payments later than 60 days will incur a $50.00 late charge per month.
(Your therapist receives payment for their services only after your payment is received thus timely payments are very
important).

I authorize this office to provide therapy service to me on a private pay basis.
I acknowledge that the purpose, process, and estimated cost for this service have been explained to me by Kitestrings Pediatric Therapy. Because my insurance does not cover this service, I agree that I am responsible for the amount due within 15 days of statement date. Should a discount be applied, I further understand that this discount may be removed if the balance due is not paid within the above stated time frame.
I agree that I have chosen this service on a private pay basis and I waive the right to have any insurance filed by the practice on my behalf. I also agree that no insurance discounts may be applied towards this debt.

I have engaged Kitestrings Pediatric Therapy to provide therapy services for my child.
I have been informed that as with any claims submitted by the healthcare provider, my health plan may deny payment for services.
I understand that if the health plan denies payment, or there is a balance due after insurance, I agree to be personally and fully responsible for payment of the services rendered.

Insured / Policy Holder's Name:*

First NameLast Name

Insured / Policy Holder's Date of Birth:*

Date

Insured / Policy Holder's sex (as stated on their insurance policy).*

MaleFemalePrefer not to answer

Is the Insured / Policy Holder's address the same as the client's address?*

YesNo

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please provide the details of your insurance information below:*

Please provide the insurance services phone number (Back of insurance card).* *

*The insurance services phone number is located on the back of the insurance card. There will typically be more than one number. Please provide the 'providers' phone number. If not, please provide the general 'members services' phone number.

Is this a Marketplace Plan?*

YesNoUnsure

Please take a photo of the FRONT of your insurance card.

Please take a photo of the BACK of your insurance card.

Please take a photo of the FRONT of an up-to-date photo ID (ie. Driver's license)

Some health insurance plans will only pay for services that they determine to be “reasonable and necessary.” If an insurance plan determines that a particular service, although it would otherwise be covered, is “not reasonable and necessary”, the insurance plan may deny payment for that service. Please know that we will make every effort to collect the amounts due from the insurance provider, including following any appeals process that the provider has in place for collection of these claims.

I , First Name* Last Name* , have been informed on this date Date* by my therapy provider (and/or staff) that, as with any claims submitted by the healthcare provider, that my health plan may deny payment for the services I am pursuing at Kitestrings Pediatric Therapy. I understand that if the health plan denies payment, I agree to be personally and fully responsible for payment of the services rendered. I also understand that I may have a deductible that must be met before insurance will begin paying Kitestrings Pediatric Therapy. It is my responsibility to know my deductible and understand that I am fully responsible for payment of these charges for services rendered.

I have read, understood and agree to the stated policies and agreements.
I hereby certify that, to the best of my knowledge, the provided information is true and accurate.
I acknowledge that this Agreement will automatically be renewed
and will continue for future Service Years unless I notify Kitestrings Pediatric Therapy of my intention to terminate.
I acknowledge that either I or Kitestrings Pediatric Therapy may terminate this Agreement at any time upon 30 days written notice. If either party terminates this Agreement, any final balance due will be charged by the method on file within the 30 day period.

Parent/Guardian Name*

First NameLast Name

Client (patient) Name*

First NameLast Name

Date*

Date

Client Payment Information

Payment Information

Private Pay

Bill Insurance

Provider's Notice:

Policyholder Patient Agreement

PLEASE READ AND SIGN