I acknowledge and accept full and complete responsibility for prompt payment of all services rendered to the patient whose name is specificed below, by The Kids’ Communication Center, LLC. I acknowledge that prompt payment is upon receipt of invoice. I acknowledge that I have received written explanation of the fee schedule and the cancellation policy and that I agree to both.
I understand that health insurance policies and reimbursement are between myself and the health insurance company, that all services rendered to my child are charged directly to me, and that I am personally responsible for payment to The Kids’ Communication Center, LLC. I understand that agreements regarding fee schedules and charges for canceled appointments are between myself and The Kids’ Communication Center, LLC, and are not related to potential health insurance coverage.