I authorize the Therapy Place to charge the $50 to the credit card provided in the event of a no-show or in the event of a cancellation without 24-hour notice. I agree to pay for this purchase in accordance with the cardholder agreement.

You Are Responsible For Payment
You or your guarantor is responsible for payment for services provided by us at the time the medical services are provided. You further agree that you will be responsible for payment for disclosed non-covered services.
You agree that if payment in full is not received from your insurance carrier or from your personal
funds, and if a lawsuit or action is brought to collect this account or any portion of it, that you
agree to pay the costs of collection, including but not limited to, taxable and nontaxable costs and
disbursements provided by statute as well as attorneys’ fees amounting to one-third of the total
outstanding balance.

Health Insurance
If payment for the services that we provide for you may be covered by insurance, we will provide you with a copy of your bill at each visit which contains all the information necessary for you to bill your insurance carrier. We are required by law to submit the bill to your insurance carrier if the service provided is a covered service under your insurance plan. If we do this, it is still your responsibility to pay for any and all medical services provided to you and to request payment from your insurance carrier. If we have given you an estimate on the payment that your insurance carrier will pay, please understand that this is only an estimate and not a guarantee of payment by your insurance carrier. When an insurance carrier gives us “authorization” it is only a determination by
the insurance carrier that your policy provides coverage in general for the services that are to be
provided. There may be additional reasons why your insurance carrier will not, ultimately, pay for the services that are provided. You agree that regardless of what your insurance carrier ultimately pays, you are responsible for payment for the services.

Minors
If you are under the age of 18 at the time services are provided, your parent’s or legal guardian’s signature below constitutes an agreement and guarantee by your parent or legal guardian that they and you are responsible for paying for any and all fees. Your parent’s or legal guardian’s signature also is an acknowledgment that the services provided are “necessary” expenses.

Returned Checks
Returned checks are subject to a $25.00 returned check fee.

Authorization for Treatment
I hereby consent to and authorize The Therapy Place, PC, to perform occupational therapy treatment,
under the direction and supervision of a licensed occupational therapist, necessary for the above
named patient that The Therapy Place, PC or the patient’s physician advises to be necessary.
I understand and am informed that, as in the practice of medicine, there may be some risks associated
with the provision of occupational therapy. I understand that I have the right to ask about those
risks and to have any questions about my child’s condition answered prior to treatment.
I acknowledge and agree that either a parent or legal guardian will be present during each
treatment session.

I have carefully read and I fully understand this Informed Consent Form. I furthermore had the
opportunity to discuss this Form with the treating occupational therapist.

I understand that patients’ protected health information may be used and disclosed for treatment,
payment, or healthcare operations purposes. For a more complete description of the potential
uses and disclosures of protected health information, please refer to the Notice of Privacy Practices
issued on the first day of treatment. You have the right to review the Notice prior to signing this
Consent Form. To obtain additional copies of the Notice, please contact our office at 732-813-4263
I acknowledge that I have read agree to all of the information stated above.

I understand that I am financially responsible for all services rendered whether or not paid for by insurance. If a referral form is required by my insurance company for a service and I neglect to secure it, I am financially responsible for the service provided. I hereby authorize the release of medical information deemed necessary by The Therapy Place, PC.

I authorize The Therapy Place to communicate with my child's school regarding my child's therapy.

I authorize the release of any medical information necessary to process my claims. This authorization remains valid until I give written notice that it is explicitly revoked.

I allow students to observe my child's therapist during treatment.

I hereby authorize The Therapy Place to send me appointment reminders as well as other communications via e-mail or text message using the following information. Email reminders may contain patient or clinic information such as, but not limited to, patient first name and clinic location.