"*" indicates required fields Thank you for choosing Peak Pediatrics LLC to serve you. We are committed to providing you with the highest quality care. Please know that the timely payment of your bill is an integral part of our service and as such, this payment policy is an agreement between you and Peak Pediatrics LLC for payment of services provided. By signing this policy, you are agreeing to pay for services provided to you or your family member. Please read the following information carefully: All therapy fees (including session fees and/or co-pays, if applicable) are due at the time of service. We accept the following payment methods at this time: Cash Checks (Made payable to “Peak Pediatrics LLC”) Credit Cards We will provide you with an invoice outlining the services rendered and the amount charged. Name of Client* Date of Birth* MM slash DD slash YYYY Please read and check all boxes to acknowledge understanding and the sign below:I understand that I am responsible for all costs / fees that any third-party payer (ex. insurance company, private school, etc.) does not cover. In the event that a third-party payer source determines that rendered therapy services are “not covered” or otherwise denied, I will be responsible for all outstanding charges. I understand that I will be billed accordingly and will be responsible for immediate payment. I also understand that Peak Pediatrics LLC will not become involved in disputes between you and your third-party source regarding uncovered charges or reasons for denial.* I Understand I understand that if fees are not paid in full, treatment sessions may be postponed or cancelled until payment is received.* I Understand Print Name of Client* Date of Birth* MM slash DD slash YYYY Signature of Client, Guardian or Responsible Party*Relationship to Client PhoneThis field is for validation purposes and should be left unchanged.
