Financial Policy

Thank you for choosing Greater Atlanta Speech and Language Clinics, Inc., (GASLC, Inc.) to provide your speech, occupational and/or physical therapy. We are committed to your treatment being successful. Please understand that payment of your bill is considered a part of your treatment. The following is a statement of our Financial Policy, which we require that you read and sign prior to any treatment.

Our practice is committed to providing the best treatment possible for our patients and we charge with what is usual and customary for our area.

WE ACCEPT PAYMENTS BY CASH, CHECKS, AND MOST MAJOR CREDIT CARDS.
GASLC, Inc. regards the adult party who signs below as “Parent or Responsible Party” to be the responsible guarantor for that patient’s account in all cases and without exception.

We are considered in-network for the following insurance companies: Cigna, United Healthcare, Blue Cross/Blue Shield, Aetna, Ambetter, and Coventry. Although we are considered to be in-network with your insurance carrier, this is not a guarantee of coverage or payment for our services. We also accept Deeming Waiver, PeachState, Amerigroup, and Medicaid for children up through age 21.

Your co-pay/coinsurance amount is expected at each visit. 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.

All insurance claims following treatment at Greater Atlanta Speech and Language Clinics (GASLC) are filed as a courtesy to you and are subject to review by your insurance carrier. GASLC will submit a claim with your insurance carrier up to 2 times per appointment and any further insurance appeal is solely your responsibility unless a secondary source of payment is established. This includes, but is not limited to: insurance denial of coverage, policy deductibles, policy maximums, annual or lifetime benefits being exceeded, and GASLC not receiving payment within a reasonable amount of time even if you are in an appeals process with your insurance carrier.*

I understand

Client/Parent Initials*

In the event your insurance company denies coverage, you will be responsible for payment of all charges and we require the balance of the account on the first of every month. Please be advised that if we are filing with a private insurance company that it can take up to 30-60 days or longer to receive an EOB (explanation of benefits). By the time we know whether or not your insurance company will pay, you may have accumulated more than one month’s invoice. Please plan ahead as you will be expected to pay the balance on all of the invoices by the first of the following month.*

I understand

Client/Parent Initials*

A request for preauthorization DOES NOT guarantee approval of coverage, and coverage is not retroactive. Should you prefer to begin services and pay privately while preauthorization is being pursued, you may do so. All payments must be made at time of services rendered and are not reimbursable by insurance if approved.*

I understand

Client/Parent Initials*

You are responsible for keeping track of your number of covered visits per calendar year. If you exceed the maximum number of visits as provided by your insurance coverage, YOU WILL BE RESPONSIBLE FOR PAYMENT IN FULL.*

I understand

Client/Parent Initials*

A request for preauthorization DOES NOT guarantee approval of coverage IF you are out of allowed visits. Should you continue services, if services are not paid by your insurance, you are financially responsible at the contracted rate.*

I understand

Client/Parent Initials*

A re-evaluation is required by most insurance companies once per year. The charges for a yearly re-evaluation may differ from your regular therapy sessions. My initials indicate that I understand I will be responsible for any co-insurance, copay, or deductible amounts not paid by my insurance company for the yearly re-evaluation.*

I understand

Client/Parent Initials*

GASLC, Inc. will exercise the right to charge 10% interest on past due accounts. This will accrue each 30 days the account is overdue. Additionally, there may be a $10 late processing fee per month.*

I understand

Client/Parent Initials*

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.*

I have read the above Financial Policy and understand and agree to abide by this policy.

Signature

Name of Client*

First NameLast Name

Name of Parent/Guardian/Responsible Party*

First NameLast Name

Email*

example@example.com

Date*