Patient Service Agreement

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Kid Talk
PO Box 34
Victoria, MN 55386

FAX: 952-443-9804
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Your case history and any other requested information must be received no later than one week before your scheduled appointment.

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  • Attendance Policy

  • We are committed to providing consistent quality services to our clients. We expect that same commitment from the families we serve. Our therapists make a professional recommendation as to the frequency and duration of your child’s therapy to ensure you child progresses appropriately. Your child will make the most progress in therapy with consistent attendance. It is also important that you arrive on time so that your child can benefit from a full session. Families that choose to receive services for their child at Kid Talk must adhere to following cancellation policy:

    1. When possible contact Kid Talk 24 hours prior to the scheduled appointment. Therapy sessions that are not cancelled will be charged a “No Show” fee of $75

  • 2. Each family will be allowed 2 cancellations per calendar year for instances when you are NOT able to reschedule your child’s appointment. Once your allotted cancellations are used, families must reschedule their cancelled session within 60 days of the originally scheduled appointment. If the session is not rescheduled within 60 days there will be a $50 charge. This is necessary due to the therapists time spent planning and setting up for your child’s therapy session and her inability to see another child during that time slot. Families are responsible for keeping track of your used cancellations.

  • 3. We will try to reschedule your child with your regular therapist but can not guarantee that your therapist will be available. Seeing a different therapist is a wonderful opportunity to gain fresh ideas and to assist your child with tolerating changes and encouraging flexibility in a safe environment.

    4. Frequently missed therapy sessions result in a lack of progress for your child. Should you fail to cancel an appointment and/or not show up at your scheduled appointment three times, therapy will be terminated. The same will hold true for frequent cancellations without rescheduling. You will be billed for any outstanding balance.

  • 5. At the time of discharge, any remaining appointments that have not been rescheduled will be billed at the above rate of $50/session.

    It is the patient/parent(s)/guardian responsibility to inform Kid Talk Inc. of any and all changes in insurance information, including group policy number, identification number, phone numbers, addresses, etc. as soon as possible. Failure to do this could result in total patient responsibility for charges incurred.

    Out of Pocket Policy: Insurance policies are contracts made between the patient and the insurance company. When insurance does not provide payment of therapy costs, payment of the bill is your responsibility. If for any reason treatment is denied by your insurance, we will charge for the usual and customary amount paid by your insurance company.
    ▪ For your benefit and to insure the highest level of coverage from your insurance company, we choose to participate in most insurance plans, which results in lower payments to the provider but lower costs to the patient.
    ▪ Both private insurers and the Federal Government prohibit waiving and/or reducing the copayments.
    ▪ Due to binding contracts with each insurance company and industry wide standard ethics, we are required to collect all copayments and deductibles that are due to your specific policy. We are obligated to be in compliance with these standards.
    In cases of hardship: The parent/legal guardian must provide written notification to Kid Talk Inc. detailing the circumstances warranting a need for a reduced fee. Completion of a personal financial statement form is required to be completed for our consideration. If granted, reduced fees are provided for a period of six months. Prior to the end of the six months, if circumstances have not changed, parents may request an extension in writing.

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