Before we get started, we need to gather some additional information about you and your child including general contact information, a brief health history, and insurance information. In addition, we will ask you to review and sign our Notice of Privacy Practices, Consent for Treatment, and Financial Policy & Agreement. We are looking forward to working with you and your child!
Enter Primary Insured's information below:
FINANCIAL POLICY & AGREEMENT
Thank you for choosing Tobogo Therapies LLC dba TherapyWorks to provide therapy services for your child! We are committed to your child’s treatment being a positive experience, and we want our billing process to be as straightforward as possible. After all, our goal is to make all things related to your child’s speech therapy easier for you! This document explains our billing process but please do not hesitate to contact us at any time with questions or concerns about this financial policy or any invoices that you receive. We are here for you and want to ensure that you are completely satisfied with your experience with TherapyWorks!
Insurance: We are an in-network provider of speech therapy services with BlueCross BlueShield and Cigna and of occupational therapy services with BlueCross BlueShield. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract or exactly what benefits are included or excluded in your plan. We encourage you to confirm your policy’s applicable benefit for therapy services, as we are not responsible if the benefit quoted differs from your insurance entity’s actual payment. If we are not an in-network provider for your particular insurance entity or if your insurance entity refuses to pay for any portion of the services rendered, the “Parent or Legal Guardian” will be billed directly and will hold full responsibility for any unpaid services.
Fee Schedule: Click here to view
Invoices: Invoices will be emailed bi-weekly. The total amount of billable services and any applicable co-insurance or co-pay will be due within 15 days after invoice.
Payments: We accept credit card (Visa, Mastercard, American Express, and Discover), Chase QuickPay® and check as payment options. All clients must have a credit card on file to receive services. Unless prior arrangements have been made for payments, you will be automatically enrolled in autopay and your card on file will be charged for services. For insurance clients, your insurance will be billed for services before you are invoiced. You will receive a paid receipt once your card is charged. If your credit card is declined or cannot be processed or if you have made prior arrangements to pay via an alternate method, you will receive an invoice via email that will be due within 15 days.
Payment by check
If you are paying by check, please send to:
P.O. Box 213
Winnetka, IL 60093
Payment via Chase QuickPay®
If you are paying via Chase quick pay, please send to the following email address:
Payment via credit card
We accept Visa, Mastercard, American Express, and Discover. We will collect credit card information before services begin and it will be stored in our billing software. If you need to update your card on file, please reach out to us at 312-780-0820 or
Late Payments: Payments not received within 30 days of invoice will be charged a $20 late fee, and any unpaid balances 30 days past due will accumulate 5% interest at the 1st of each new month that the balance is past due. If a bill is more than 90 days past due, we reserve the right to contact a collection agency.
Cancellation Fees and Policy: The late cancellation / no show fee is $50 and is not billable to insurance. If you are unable to attend a session, please cancel your session a minimum of 24 hours in advance. That said, we understand that children may present symptoms of illness the morning of his/her therapy session. Parents will not be penalized for late cancellations due to illness. If you do need to cancel the same day as services, please text your therapist directly.
ASSIGNMENT AND RELEASE: I AUTHORIZE THERAPYWORKS, TO RELEASE ANY INFORMATION TO MY INSURANCE ENTITY THAT IS PERTINENT TO PROCESSING MY CLAIM. I HAVE READ THIS FINANCIAL POLICY AND AGREEMENT AND UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR PAYMENT TO THERAPYWORKS FOR THERAPY SERVICES NOT COVERED OR CONTRACTED BY MY INSURANCE ENTITY. I UNDERSTAND AND AGREE TO THIS FINANCIAL POLICY AND AGREEMENT.
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOUR CHILD AND FAMILY MAY BE USED AND DISCLOSED AND HOW YOU CAN GAIN ACCESS TO THIS INFORMATION.
PLEASE REVIEW THIS CAREFULLY. If you have any questions about this notice, please contact Tobogo Therapies LLC dba TherapyWorks (“TherapyWorks”):
Tobogo Therapies LLC dba TherapyWorks
PO Box 213
Winnetka IL 60093
This Notice of Privacy Practices is provided to you as a requirement of the Health Insurance Portability and Accountability Act (HIPAA).
TherapyWorks is committed to treating and using your protected health information responsibly. This Notice of Health Information Privacy Practices describes the personal health information TherapyWorks collects, and how and when its representatives may use or disclose that information. This notice also describes your rights as they relate to your Protected Health Information. This Notice is effective September 1, 2017 and applies to all protected health information as defined by federal regulations.
ACKNOWLEDGEMENT OF RECEIPT OF THIS NOTICE
You will be asked to sign an acknowledgement of receipt of this Notice. TherapyWorks’s intent is to make you aware of the possible uses and disclosures of your protected health information and your privacy rights. The delivery of your therapy services will in no way be conditioned upon your signed acknowledgement. If you decline to sign the acknowledgement, TherapyWorks will continue to provide treatment, and will use and disclose your protected health information for treatment, payment, and health care operations when necessary.
UNDERSTANDING YOUR HEALTH RECORD/INFORMATION
A record of each therapy session is made. This record may contain your symptoms, examinations and results, diagnoses, treatment, and a plan for future care or treatment. This information, often called your health or medical record, serves as a:
Understanding what is in your record and how your health information is used helps you to: ensure its accuracy, better understand who, what, when, where, and why others may access your health information, and make more informed decisions when authorizing disclosure to others.
YOUR HEALTH INFORMATION RIGHTS
Although your health record is the physical property of TherapyWorks, the information belongs to you. You have the right to:
THERAPYWORKS’ RESPONSIBILITIES: TherapyWorks is required to:
TherapyWorks reserves the right to change Privacy Information practices and to make the new provisions effective for all protected health information its representatives maintain. Revised notices will be available as requested. TherapyWorks will not use or disclose your health information without your authorization, except as described in this notice. TherapyWorks will also discontinue to use of your health information after it has received written revocation of the authorization according to the procedures included in the authorization.
EXAMPLES OF HOW THERAPYWORKS MAY USE OR DISCLOSE YOUR HEALTH INFORMATION
For Treatment: TherapyWorks may use your health information to provide you with services. This may include recording information regarding your treatment, the course of action that TherapyWorks will take to treat your issues, and how you respond to these activities.
For Payment: TherapyWorks may use and disclose your health information to others for purpose of receiving payment for treatment and services that you receive. For example, a bill may be sent to you or a third-party payor, such as your insurance company or health plan. The information on the bill may contain information that identifies you, your diagnosis, and the treatment used in the course of treatment.
For Quality Control: TherapyWorks may use your information to assess the treatment provided and outcomes in your and similar cases. This information would then be used to continually improve the quality and effectiveness of the therapeutic services TherapyWorks provides.
Appointments: TherapyWorks may use your information to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you.
Directory: Unless you notify TherapyWorks that you object, TherapyWorks may use your name if you have been transported to a hospital or other facility to check on your status.
Notification or Communication with Family Members: TherapyWorks’ therapists, using their best judgment, may use or disclose information to notify or assist in notifying family relatives, personal representatives, close personal friends, or other people you identify; information relevant to that person's involvement in your care or payment information related to your care.
Research: TherapyWorks may disclose information to researchers when their research has been approved by an institutional review board (IRB) that has reviewed the research proposal and established protocols to ensure the privacy of your health information.
Public Health: Your health information may be used or disclosed for public health activities such as assisting public health authorities or other legal authorities to prevent or control disease, injury, disability, or for other health oversight activities.
Required by Law: TherapyWorks may use and disclose information about you as required by law. For example, TherapyWorks may disclose information about you for the following purposes:
Federal law makes provision for your health information to be released to an appropriate health oversight agency, public health authority, or attorney, provided that a workforce member or business associate believes in good faith that TherapyWorks has engaged in unlawful conduct or has otherwise violated professional or clinical standards, and is potentially endangering one or more clients, workers, or the public.
Health and Safety: Your health information may be disclosed to avert a serious threat to the health or safety of you or any other person pursuant to applicable law.
Government Functions: Specialized government functions such as protection of public officials or reporting to various branches of the armed services that may require use or disclosure of your health information.
OBTAINING AND STORAGE OF INFORMATION
Your information will be obtained from medical facilities, agencies, and other persons involved with the health care of your child and family only with your written consent. Your signature is required in order for healthcare information to be obtained from outside sources.
Medical information may be delivered through U.S. mail or facsimile services. All documentation delivered via U. S. mail will only be opened by TherapyWorks. Facsimiles arrive in a private location and are also only obtained by TherapyWorks. Once these documents arrive, they are placed into your child’s secure file. Other professionals may also request contact via telephone. Minimal information will be given via cellular communication in public locations. Should another professional wish to complete such a call, a request will be made to reschedule for another time or TherapyWorks will move to a location where your privacy can be assured.
SECURITY TECHNOLOGY AND PRACTICES
Your sensitive data is hosted in a Tier 1 secure hosting provider specializing in helping healthcare organizations achieve and maintain HIPAA and HITRUST security requirements:
Once medical information has been obtained, it will be placed and stored on TherapyWorks’s secure software system. No one other than TherapyWorks will have access to these files without your written and signed consent.
After six years of inactive status, TherapyWorks may destroy your hard copy stored medical information and delete electronic medical information. If destroyed, hard copy medical information will be shredded and/or discarded.
For more information, to discuss a problem, or if you have questions and would like additional information, you can contact TherapyWorks:
Winnetka, IL 60093
If you believe that your privacy rights have been violated, you can discuss the situation with TherapyWorks, or you can file a complaint with the Office for Civil Rights, U.S. Department of Health and Human Services. There will be no retaliation for filing a complaint with either TherapyWorks or the Office for Civil Rights. The address for the OCR is listed below:
Office for Civil Rights-U.S. Department of Health and Human Services
200 Independence Ave.,
1W. Room 509, HHH Building
Washington, D.C. 20201
866-OCR-PRIV (866-627-7748) or 886-788-4989 TTY