Terms & Conditions

Private Payment Agreement

STARS Therapy Inc only accepts private payment and does not have existing contracts with any insurance companies. The following agreement outlines the terms of payment between clients who choose STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP. 

*Please initial each item to indicate that you have read, understand, and agree with the following items: 

______ I am choosing not to use any Health Insurance Coverage to pay for occupational therapy services with STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP. 

_____ I understand that STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP will not bill any third party or insurance companies for any services or fees incurred while my child is evaluated/treated by STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP. 

_____ I understand that if I decide to use my insurance coverage I will alert STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP in writing, and that any treatment provided before that date will not be billed to my insurance. 

_____ I understand that STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP is not be a provider with my insurance company. 

_____ I understand I am solely responsible for any fees incurred while in treatment with STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP. 

_____ I am aware of the fee per session for occupational therapy treatment with STARS Therapy Inc/Blair Carsone PhD, MOT, OTR/L, BCP.

By signing below, I am acknowledging my understanding and agreement to the information

Print Name:_________________________________________________________________________________

Signature: __________________________________________________________________________________

Date: ______________________________________________________________________________________

Relationship to Child: _______________________________________________________________________

Child’s Name: ______________________________________________________________________________

Child’s Date of Birth: ________________________________________________________________________