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Communication Clubhouse, Inc.
2901 Finley Rd., #102 Downers Grove, IL 60515
4958 N. Milwaukee, Chicago, IL 60630
Patient Payment Responsibility
Please read all the information carefully. This is a binding legal document.
Patient Name:_____________________________ Date of Birth: _____________
PATIENT PAYMENT LIABILITY: I acknowledge that I am legally responsible for all services provided by
Communication Clubhouse, Inc. (CCI) and I assign and authorize payment to CCI by my insurance carrier for
services provided to me or to the patient named above. I further understand that:
1. it is my responsibility to confirm my insurance benefits and options and to provide correct and current
information regarding my policy to CCI.
2. My insurance carrier may not approve or reimburse my services for reasons including but not limited to usual
and customary rates, benefit exclusions, coverage limits, lack of authorization, or medical necessity.
3. My insurance company will not make a final determination as to whether or not it will reimburse any
given service until it has reviewed submitted claims, and that this process may take weeks, or even months.
4. I will pay for services which are not paid for by insurance within 60 days of the claim submission.
5. If I receive any reimbursements from a third party (insurance co., school, etc.) to apply toward these services, I
will inform and reimburse CCI within one week of receipt of these funds.
6. I verify that the demographic and insurance information provided to CCI is correct and it is my
responsibility to update CCI with any changes as they occur.
7. In the event that I default on any of the terms of this agreement, I agree to pay all costs of collection and
reasonable attorney’s fees associated with CCI’s attempt to secure payment from me.
All fees not covered by insurance are due at time of service, except as otherwise contractually provided.
RELEASE AND CONSENT: I authorize the release of any medical information necessary to process claims and
consent to the rendering of care and service by CCI and its clinical staff for myself or for the patient named above.
SCOPE AND TERM OF AGREEMENT: This agreement covers any therapy, consulting or diagnostic services
received by Clubhouse staff, which may include Speech/Language Pathology, Occupational Therapy, Counseling or
Physical Therapy. This agreement remains in effect for the entire time that therapy services are received from CCI –
unless replaced with another signed document at a later date.
FAMILY OUT OF POCKET PLANS: All patients who are uninsured, out of network, denied by insurance or
who choose not to utilize insurance for other reasons are eligible for our Family Out of Pocket plans.
Maximum Out of Pocket Cap:
 $95/visit for individual therapy in clinic
$125/ visit for Home based Therapy
 $50/ 30 min. visit for individual therapy in clinic $350 per Evaluation (Speech/OT/PT)
Tuition Packs: This is the most economical financial arrangement for those who are not
using insurance and include rates that are even lower than the Maximum Out of Pocket rates.
Call our billing department or clinic manager to get more information.
Responsible Party: ___________________________
Relationship to Patient: _______________
(Print)
Signature: ______________________________

Date:__________