Authorization Form

Policy and Payment Authorization 

SENSORY BOUNCE THERAPY IS A YEARLY THERAPY PROGRAM WITH A MONTHLY FEE OF $400.00, CHARGED ON THE FIRST DAY OF EVERY MONTH.( A NON REFUNDABLE DEPOSIT OF $200.00 IS DUE AT THE TIME OF REGISTRATION).

PARTICIPANTS WILL RECEIVE AN INSURANCE READY RECEIPT FOR $100.00 PER SESSION REFLECTING THE ACTUAL COST OF EACH SESSION AT THE END OF EVERY MONTH.

NEW PARTICIPANTS ARE REQUIRED TO COMMIT TO THE PROGRAM FOR ONE MONTH.

AFTER 1 MONTH, PARTICIPANTS MAY OPT OUT OF SENSORY BOUNCE THERAPY AT ANY TIME PROVIDING WE RECEIVE A REQUEST BY EMAIL ON OR BEFORE THE 25TH OF THE MONTH. EMAILS CAN BE SENT TO INFO@SENSORYBOUNCE.COM OR TO OFFICE.MSKYDELL@GMAIL.COM 

PLEASE NOTE THAT THE COST OF THE PROGRAM WAS DESIGNED TO ACCOMMODATE FOR MISSED SESSIONS, VACATION BREAKS AND MISCELLANEOUS UNEXPECTED CANCELLATIONS BY THE THERAPIST OR FACILITY.

SENSORY BOUNCE THERAPY GUARANTEES THAT THERE WILL BE A MINIMUM OF 3, AND MAXIMUM OF 5 SESSIONS PER MONTH). THERE ARE NO REFUNDS OR CREDITS FOR MISSED OR CANCELLED SESSIONS.

FIRST TIME PARTICIPANTS JOINING MID MONTH WILL BE CHARGED IN FULL FOR THE FIRST MONTH AND PRORATED FOR THE SECOND MONTH.

IN THE EVENT THERE ARE ONLY 2 SESSIONS IN A GIVEN MONTH PARTICIPANTS WILL BE CHARGED $200.00 FOR THE VISIT FOR THAT MONTH.

BY SIGNING BELOW YOU ARE ACKNOWLEDGING THAT YOU AGREE TO HAVE THE CARD YOU SUBMITTED ON YOUR REGISTRATION FORM, AUTOMATICALLY CHARGED BY SENSORY BOUNCE, LLC AT THE RATE OF $400.00 MONTHLY UNLESS OTHERWISE AGREED UPON AND THAT YOU AGREE TO THE TERMS OF THE PROGRAM STATED ABOVE.

IF YOU DO NOT HAVE INSURANCE PLEASE CALL THE OFFICE TO DISCUSS ALTERNATE PAYMENT PLAN AND RATES. WE CAN OFFER A 20% OFF DISCOUNT FOR PEOPLE WITHOUT OUT OF NETWORK BENEFITS. .

PLEASE ACCEPT AND SUBMIT THIS POLICY AND PAYMENT AUTHORIZATION FOR YOUR REGISTRATION TO BE COMPLETE.