Patient Information
Welcome Friends of Pediaprogress
Complete our new patient forms and review our policies and procedures
Policies & Procedures
Financial Agreement / Policies
Pediaprogress is contracted with Blue Cross Blue Shield PPO, Aetna and Cigna insurance companies. All other insurance policies will be billed with Pediaprogress as an “out-of-network” provider.
Payment is due at the time of services for patients who have any other insurance provider.
1. I agree to apply for and maintain eligibility for any third party coverage that I am eligible for and to promptly transfer to Pediaprogress, Inc., any reimbursement to which I or any individual, for whom I am the responsible party, may be entitled to receive.
2. I authorize Pediaprogress, Inc. to bill any responsible third party now or in the future for payments for all services rendered.
3. I agree to pay my established co-payments at time of service. I understand that failure to do so will result in the cancellation of scheduled therapy sessions. Continued failure to make payments may result in termination from services.
4. I agree that all benefits for services rendered will be made directly to Pediaprogress, Inc. If benefits cannot be assigned, I agree to reimburse Pediaprogress, Inc. within seven (7) days of receipt of any third party payment. I also authorize Pediaprogress, Inc. to contact any third party or company to request notification of payments.
5. I agree to provide Pediaprogress, Inc. with all necessary information to file claims including but not limited to including signatures, account numbers and names of third parties.
6. If I make a claim against an individual, company or third party for personal injury, malpractice, non-payment of claim, etc., I will pay Pediaprogress, Inc. for the total unpaid balance for services rendered from that claim.
7. I agree that I am liable for any services, or any portion of services not covered by third party reimbursement. This includes rendered services which may be determined to be medical unnecessary by my insurance company upon claim submission.
8. I agree to make payment within thirty days of any outstanding balance. A $5 late fee will be added to balances over 60 days past due each month until paid in full. Your account will be in default and may be referred to a collection agency if you do not respond to invoice requests for more than two months. Pediaprogress charges a $25 returned check fee.
9. I agree to notify Pediaprogress, Inc. immediately of any change in my financial circumstance that affects this agreement including, but not limited to, change of insurance coverage.
10. Pediaprogress, Inc. has the right to terminate services at any time without the release of responsibility to pay for services rendered to date of termination. Some of the reasons for termination include, but not limited to: submission of false information, non-compliance with attendance policies, failure to make timely payments; non-compliance with any provisions of this contract.
11. I authorize the release to any insurance company, third party, or my employer any information from my medical records as necessary to complete or process any claim for benefits. I understand that such information might be confidential under Federal or Sate law, but I waive confidentiality for the purpose set forth.
Additional Policies & Procedures
EVALUATIONS:
Evaluations are typically 45 to 90 minutes in length. A complete report will be prepared and is included in this fee. For those with a non-contracted insurance company, half of the fee for an evaluation must pay prior to the evaluation. The other half will be invoiced with the report.
TREATMENTS:
Sessions are typically 30-55 minutes in length. We ask for parents/guardians to enter the treatment room during the final 10-15 minutes of the session with the therapist to discuss your child’s progress. Please keep a cell phone with you for emergency contact if you leave Pediaprogress’ facility while your child is in a session.*Please answer yes or no to the following:
I agreeYesNo
TREATMENT PLANS (a list of goals) & RE-EVALUATIONS:
Treatment plans are provided for patients every six months.
Re-evaluation of your child’s skills is required after six to twelve months of sessions. Accurate test scores will allow our therapists to provide the most effective treatment and set appropriate goals.
CANCELLATIONS (***IMPORTANT):
Consistency of attendance to therapy is important for your child's progress. PLEASE CALL, E-MAIL, OR LEAVE A VOICE MESSAGE BEFORE 9:00 AM the day of your session if you are unable to keep an appointment to avoid being charged for the cancelled therapy session.
A cancelled or missed therapy session may be billed to you. This fee is NOT billable to insurance.
We do NOT guarantee your child's weekly or bi-weekly appointment time will be reserved, if he/she misses more than TWO CONSECUTIVE WEEKS. If you need to take an extended break from therapy, please contact us at least one week prior to your return and we try our best to schedule your child's therapy in a convenient time for you. Your child may need to be placed on a waitlist.
If your child has a 20% or greater cancellation rate and you are not able to make up missed sessions on other days offered, we will ask you to take a break from therapy until your schedule allows for more consistency.
CONVERSATIONS OUTSIDE OF THERAPY SESSIONS:
Any communication outside of a therapy session with your child's therapist via telephone, email and /or texting will be billed at a rate of $40.00 for every 15 minutes. This fee is not billable to insurance and must be paid within 30 days.
SCHOOL MEETINGS:
You may request a team member from Pediaprogress to attend a meeting at your child’s school. It is our discretion if a team member attends a meeting. Payment is required in advance for staff from Pediaprogress to attend any meetings and is billed at our current therapy rate.
Please contact us at 630.929.0122 with questions regarding Pediaprogress’ policies and procedures.
