PlayRx Private Pay Agreement
This Private Pay Agreement is to outline payment for PlayRx services in the absence of In Network Insurance or by the decision of the beneficiary's representative for PlayRx to not bill an In Network Insurance. These rates also apply to services continuing outside of the parameters of the beneficiary's In Network Private Insurance policy, such as after the visit limit is met.
PlayRx Private Pay Rates:
Speech/Occupational/Physical Therapy Evaluation: $200/hour Speech/Occupational/Physical Therapy Treatment: $100/hour
Child’s First Name
Child’s Last Name
Parent/Caregiver full name
By signing, I am agreeing to pay the rates listed above for the clinical services provided to my child by a Licensed and Certified PlayRx Therapist.
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