Helping Hand Rehabilitation Center

9649 W. 55th Street

Countryside, Illinois60525

SERVICE AGREEMENT FORM

GENERAL

Service Agreement

Page 2

Parents/caregivers MUST remain on the premises during child’s session.

Services are scheduled by appointment only.

COSTS

The cost for any therapy evaluation will be $650.00(includes the evaluation and write-up time).

The cost for Individual Therapy Services to be provided total $250.00/hour.

FINANCIAL RESPONSIBILITIES

Statements will be sent monthly to families; the amount due from patient is due in full upon receipt of each statement.

I am responsible for all co-payments, deductibles, and co-insurance amounts that are deducted for service payments from 3rd parties (insurance). Applicable co-payments are due at time of service.

I am responsible for all amounts due if any 3rd party payor denies service payments unless restricted per contract/Medicaid/Early Intervention.

If insurance denies a claim for a date of service per the contract, therapy will be placed on hold until an insurance review or appeal is completed. The family may continue therapy on a self-pay agreement (due at each session) until the review/appeal is finalized.

The client’s family is responsible for obtaining and renewing current authorizations, referrals and prescriptions, and that failure to ensure the aforementioned will result in the cancellation of scheduled services.

The client’s family is responsible for responding to all insurance requests for information and appealing insurance denials and/or unfavorable decisions, and that failure to assist with the aforementioned will result in the cancellation of scheduled services.

HelpingHandCenter provides the services of filing second and third party claims (i.e. insurance). The service of claim filing DOES NOT release the client family from financial responsibility for treatment costs. Insurance companies and other third party payers act as agents of the client, and payments are made on behalf of the client. When a client’s agent (i.e. insurance company) fails to make payment for services, the client remains responsible for the entire outstanding debt; a quote of benefits is not a guarantee of payment.

Client families are expected to pay outstanding balances in full each month. Any outstanding balance of $250 or more for over 30 days needs to be paid in full or a payment plan must be in place to continue therapy services. A payment plan can be set up by speaking with the Administrative Coordinator; we will individualize the plan to your family’s needs. An initialpayment on the plan will be required to continue services. If no payment is received, we will not be able to provide therapy services until the matter is resolved.

Should financial hardship arise, the client’s family should contact the Director of Clinical Services immediately to arrange a satisfactory means for addressing the obligation. It is understood that the Center, with proper notice, will suspend services at any time if determined that satisfactory progress is not being made to retire the outstanding debt.

CANCELLATIONS/MISSED APPOINTMENTS

HelpingHandCenter (hereinafter referred to as the Center) must be informed of all cancellations no less than 24 hours prior to the scheduled appointment. (A dedicated voice mail is provided for after-hour messages – (708) 352-3580, ext 388). I understand that failure to contact the Center prior to the scheduled appointment will result in a charge of $20 for that treatment time. ______(Initial)

Three consecutive cancellations or inconsistent attendance will result in the child losing their scheduled appointment time.

Three late arrivals within a two (2) month period will result in the child losing their scheduled appointment time.

RELEASE AND INDEMNITY AGREEMENT

The undersigned specifically assumes all risk of injury or damage for himself/herself and for his/her child or ward arising from any treatment at Helping Hand Center, the use of its premises or equipment, or from any portion of the therapy program including the photographing, filming, or videotaping of the person enrolled and waives any and all claims against the Center and agrees to indemnify and defend the Center against any and all claims brought by or on behalf of his/her child or ward arising from any treatment at the Center, the use of its premises or equipment from any portion of the therapy program, including the photographing, filming, or videotaping of the person enrolled. Furthermore, in consideration of the services provided under the Agreement, the undersigned hereby on behalf of him/herself and for his/her child or ward hereby releases and discharges the Center, its directors, officer, employees, and its agents, their successors, and assigns and agrees to hold it on demands, known and unknown, present or future, anticipated or unanticipated, including without limitation claims for loss or damages to property or injuries to or deaths of persons that may be asserted against it or them by or on behalf of his/her child or ward arising from any treatment at the Center, use of its premises or equipment or any portion of the therapy program.

YOUR SERVICE AGREEMENT MUST BE SIGNED AND RETURNED TO CONTINUE SERVICES. THIS SERVICE AGREEMENT IS VALID FOR THE DURATION OF YOUR CHILD’S ENROLLMENT IN THE PEDIATRIC CLINIC.

Rates are subject to change with thirty day notice.

SIGNED: DATE:

PARENT/NATURAL GUARDIAN OF:

ADDRESS:

STAFF SIGNATURE:

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