Occupational therapy fees are based on a 50 minute sessions (in-clinic or eHome Therapy) unless otherwise stated, and are as follows:

^{^}Most travel costs within the Seattle area are included in the out of clinic service fee.

Speech-language fees are based on 50 minute sessions (in-clinic or eHome Therapy) unless otherwise stated, and are as follows:

^{^}Most travel costs within the Seattle area are included in the out of clinic service fee.

Payment: Payment for initial service and evaluation/s are due at the time of service. Payment for additional therapy services is due at the end of each month. Invoices are emailed. At least 24 hours notice is required for any appointment cancellation to avoid the full fee for the scheduled service. Seattle Therapy – Skills for Life therapists will schedule a make-up session or complete treatment planning (e.g., phone consult; documentation) in lieu of missed appointments. No shows are billed the full fee.

Invoices: Seattle Therapy – Skills for Life does not submit invoices directly to medical insurance companies, nor does Seattle Therapy - Skills for Life accept payment from them. Preauthorization for services may be required prior to submitting claims to insurance carriers. The client or the parent/guardian is responsible for obtaining preauthorization, although Seattle Therapy – Skills for Life will provide written information and documentation in order to facilitate the process with your written authorization. With your authorization, Seattle Therapy – Skills for Life will submit paid invoices with claim form/s to your insurance company.

I, the client or parent/legal guardian, understand that I am responsible for all charges for services provided to me or my child by Seattle Therapy – Skills for Life. I am aware that Seattle Therapy – Skills for Life does not contract with any insurance carriers. I have been notified that it is my responsibility to contact my insurance carrier to determine whether the services by Seattle Therapy – Skills for Life meet the reimbursement criteria and whether preauthorization is required.

I agree to pay Seattle Therapy – Skills for Life for evaluation fees at the time of service. I agree to pay Seattle Therapy

- Skills for Life for additional services at the end of each month for services rendered that month. There will be a 20% fee for returned checks or those with non-sufficient funds. There will be a 10% late fee for accounts 45 days overdue. Accounts that are 90 days overdue may be referred to a collection agency and incur a 30% administrative charge and interest on the late payment.

Your signature below verifies that you have read this two page document and agree to the terms. If any part of this form is unclear, please consult with Seattle Therapy – Skills for Life prior to providing your signature.