1. I understand that as parent/guardian of the above client, I am responsible for any and all charges incurred resulting from treatment provided by Successful Pathways Behavioral Consulting, such as, but not limited to, deductibles, co-payments, co-insurance, or any non-covered services. _______ initials

2. As a service to our clients, Successful Pathways Behavioral Consulting will file your claims with your private insurance company. Insurance policies are contracts made between the client/guardian and the insurance company. We will attempt to verify client insurance benefits; however, this is not a guarantee of payment for therapy services. ________ initials

3. If your insurance company denies payment for services billed, or if your insurance company has not paid a claim within 90 days of the date of service, the balance due will automatically be transferred to the parent/guardian’s responsibility for payment in full. _______initials

4. Parent/guardian is responsible for informing Successful Pathways Behavioral Consulting of any and all changes in insurance information including group policy number, identification number, phone numbers, addresses, etc. Failure to do this could result in total responsibility of charges incurred. _______initials 5. When private paying, fees for individual therapy sessions are:

6. Fees for ABA are $75 per hour. ABA evaluations are $100 per hour. Fees include a written report and an opportunity to review the results. ________initials

7. Invoices will be created for statement account balances due. Prompt payment of balance in full is expected within 15 days of the statement date. If payment is not received within 30 days of the statement date, treatment of the client will be suspended and a 15% finance charge will be assessed. Additional 15% finance charge will be assessed for every 15 days that payment is not received._____initials

8. If your account is past 90 days due, it may be turned over to a collection agency. If you are turned over to a collection agency, there is a $50 filing/processing fee. All collection costs and attorney fees are the parent/guardian’s responsibility. Ultimately the parent/guardian is responsible for all charges incurred in our office. _____initials

9. Successful Pathways Behavioral Consulting accepts credit/debit cards, checks, and cash. There is a $30 fee for returned checks. ________initials

10. We require a valid credit card authorization on file and will bill your credit card for balances due. _____initials

11. When billing insurance, session length is determined by our contracted rate with the insurance company and is subject to change at any time. Sessions will not be less than thirty minutes in length. ______ initials

CANCELLATION, LATE ARRIVAL, and LATE PICK UP POLICIES effective 4/1/22

1. Therapy will be most beneficial to your child with consistent attendance. A 24-hour notice is required for cancellation of therapy sessions and evaluations. Successful Pathways Behavioral Consulting charges a $50 fee for any appointment, or session that is not kept or not canceled with proper 24-hour notice. In the event of sudden illness or medical condition, consideration will be given. After 3 missed appointments without proper notification or reason, your child may be subject to discharge from therapies. _________initial

2. If you arrive more than 15 minutes late for a one hour or longer session or evaluation, we will not be able to treat your child. If you arrive more than 5 minutes late for a 30 minute session, we will not be able to treat your child. After 3 late arrivals resulting in abbreviated or canceled treatment times, we reserve the right to charge a $25 fee for each future incidence. _________initials

3. Every therapist must be available to treat their next child. They are not available to watch your child in the event you arrive late, so please arrive 15 minutes prior to the end of your child’s session. The last 10 minutes of each session is critical for your therapist to meet with you and review your child’s progress. After 3 late pick-ups, we reserve the right to charge a $25 fee for each 15 minute increment until your arrival. __________initials

4. I also understand that on occasion, my child’s therapist may have a conflict or illness and need to cancel or reschedule. A make-up session will be attempted when possible with one of the therapists on staff. ________initials If you need to change/cancel your child’s appointment, contact us at 707-770-8315 phone and/or email [email protected]

ASSIGNMENT OF BENEFITS

I authorize Successful Pathways Behavioral Consulting to release any information including the diagnosis, treatment plan, evaluation  report/summaries, progress notes, and discharge summaries for any treatment rendered to my child during  the periods of such care to third party payers. 

I also authorize my insurance company to directly pay Successful Pathways Behavioral Consulting insurance benefits otherwise payable  to me. I understand that my insurance carrier may pay less than the actual bill for services. I agree to be  responsible for payment of all services rendered on behalf of my dependent(s) that are not covered by my  insurance carrier.