Attendance, Cancellation, Insurance and Payment Form
Attendance and participation in therapy along with complete compliance with any associated home programs, are essential for therapeutic success.

While iSpeak Therapy Services understands that illnesses and emergencies occur, we respectfully request that you avoid frequent cancellations or “no shows”. Please adhere to our following policy regarding providing our office with advance notification for any cancellations resulting from a conflicting appointment, vacation, obligations for work or family, or any other event.

All cancellations must be submitted 24 hours prior to your scheduled appointment, or your appointment is subject to cancellation.

A PDF copy of this Form will be sent to your Email Address.
Sign in to Google to save your progress. Learn more
What is Your Email Address? *
What is Your Child's Full Name? *
Attendance and Cancellation Policy
A fee of $25 may be assessed if the following occurs:
1. If cancellations are made less than the required 24 hours.
2. If the client fails to show up for a scheduled appointment.

This fee will be billed directly to the client and not their health insurance company, as medical insurance does not provide coverage for missed sessions.

If you reschedule / cancel for 5 scheduled appointments within 3 months, the office will reserve the right to discharge the client. Additionally, if you arrive late for a scheduled appointment, the session will still end at the scheduled time or may be cancelled.

If you fail to appear for an appointment (no show) without providing the appropriate advance notification for 3 or more appointments within 3 months, the office will reserve the right to cancel all pending appointments and to no longer offer services to you as a client.
I Agree to the Attendance / Cancellation Policy Above and am Aware of the Risks of not Adhering to it. *
Required
Payment and  Insurance Policy
Payment for service is important in any professional relationship. Payment (and/or co-pay) for your child’s therapy will be
expected at the time of service. We are able to accept cash, check, and credit/debit cards as your payment options. Meeting
this financial responsibility is one way to demonstrate your commitment to your child’s therapy.

iSpeak Therapy Services, LLC proudly accepts Medicaid and all CMO’s (WellCare, Amerigroup, Care Source and Peach State). We are not in-network with any private insurance companies. Many individuals are reimbursed by their out-of network insurance benefits for our services. It is the parent’s responsibility to seek reimbursement. Parents are also responsible for notifying the clinic if insurance information has changed. Failure to do so will result in non-covered services billed directly to you.
I Agree to the Payment / Insurance Policy Above and am Aware of the Risks of not Adhering to it. *
Required
Relationship to Client? *
Parent/Legal Guardian Signature *
By typing and submitting my name below I am agreeing that all of the information above is correct. I also acknowledge that by typing and submitting my name below I am agreeing that it will be used as my legal binding signature.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of iSpeakTherapyServices. Report Abuse