Positive verification of your coverage cannot always be made at the time of service. You will
receive services with the understanding that in the event your coverage is not effective, you will
be billed and held financially responsible for these services rendered.
I have read the above and understand my possible financial responsibilities of services rendered and hereby affix my signature as an acknowledgement of this understanding.
AS A MEDICAL PROVIDER, OUR RELATIONSHIP IS WITH YOU AND NOT YOUR
INSURANCE COMPANY. IT IS YOUR RESPONSIBILITY TO KNOW YOUR POLICY. WE CAN
ONLY TELL YOU OUR CHARGE, AMOUNT PAID AND AMOUNT OWED.
Welcome to KIDOLOGY Therapy services. We ask that you please take the time to review the following
policy regarding no show, late arrival, and cancellation of teletherapy/home/office/daycare
We understand that scheduling conflicts, emergencies, and illnesses can occur from time to time.
However, we request that you give 24-hour notice if you are not going to be able to attend your
If you need to cancel your child’s session, you need to contact the office within 24 hours.
215-330-4116 or text 267-560-7564
Failure to give 24-hour notice will result in a no show/cancellation fee of $40.
We thank you for respecting our therapists’ time and commitment to providing excellent services to you
and your family.
Should you have to cancel due to illness or death in the family, please provide a note to be exempt from
the fee- failure to provide a note, fee WILL NOT be exempt.
Read and understand this policy. You may be provided with a copy upon request.
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