Medical History Form for Big Sky Pediatric Therapy

Private Pay Teletherapy Agreement

I understand Big Sky Pediatric Therapy is accepting:

* Indicates required field

Patient's Name *

as a private pay patient for *

Occupational Teletherapy Services Physical Teletherapy Services Speech Teletherapy Services

I will be responsible for paying for any services received. Big Sky Pediatric Therapy will not file a claim to my primary insurance company for services provided for the duration of this agreement.

Please note the following Private Pay charges for services and fees as of 1/1/2020:

Evaluation- $360 per evaluation
Therapy Session- $72.50 per 30 mins/session
Consultation Fee- $36.25 per 15 mins
Late Cancellation Fee- $30 per session (Less than 24 hours notice)
No Show Fee- $60 per week
Appointment Hold- $30 per week

***Big Sky is currently offering a 10% discount on our private pay rate for all teletherapy services***

Parent or Guardian of Patient: *

Date *

I understand and acknowledge I will be responsible for the charges above. Checking this box indicates my understanding of this information and willingness to pay said fees. Checking this box also indicates my consent for teletherapy services. *

By checking this box and clicking 'Submit', I agree to the terms and conditions listed on this form

Submit

We HOPE TO SEE YOU SOON!

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