Felice Center for Pediatric Rehabilitation
7205 Aloma Ave, Winter Park, FL 32792
Tel: (321) 972-3960 Fax: (321) 972-3960 Email: email@example.com
Felice Center will bill your insurance or Medicaid for therapy service. However, if you or your child has any change in coverage, including:
...call our office immediately (321) 972-3960. We must be informed of any changes or it may be impossible for us to bill your insurance or Medicaid carrier. You may be billed for any charges that cannot be paid because of changes to you or your child’s coverage.
A $50.00 fee will be charged for all missed appointments that are not cancelled 24 hours prior to the scheduled appointment time. Your insurance company will not pay for missed visits, and you will have to pay the charge out of pocket.
No more than two (2) cancellations will be allowed in any given month with the exception of extended illness, which must be substantiated by primary care giver. Therapy cancelled more than 2 times in a month for reasons other than an excused illness then your child will be removed from the therapist schedule. You will be placed on a hold status. At that point, you will be required to call the office and start the process of obtaining therapy from the beginning without guarantee of getting the same therapist.
If your family goes on vacation for more than one week, please inform your therapist or office. Your child will be on hold. Upon return from vacation, please call the office to schedule therapy with the same therapist if available. Otherwise, a new therapist will be assigned.
As a courtesy to our patients, Felice Center will file therapy service claims with your primary medical insurance. However, our office policy is to expect full reimbursement from the patient or guardian within 15 days after receipt of invoice. Payments that are collected from the insurance carrier will be reimbursed in full to the policyholder, or applied as a credit to the policyholder’s account.
I agree to pay in full for services provided by Felice Center within 15 days of receipt of invoice and understand that any payments collected from my insurance company will be reimbursed to me in full.
Note: Patients with Medicaid coverage will not be billed upfront for services.
By signing this document, you are stating that you have read and agree to the terms listed above.
To be signed by the patient or primary guardian of patient: