Confidential Credit Card Form

    OT Studios, Inc is a trustworthy, ethical company that strives for honest billing. By signing below I authorize OT Studios, Inc to charge my credit card for any documented charges. I understand that I am responsible to pay the Evaluation and Treatment session charges, unless I am in network with an accepted insurance at which point I will be responsible for my copayment and any remaining balance not paid by my insurance. I acknowledge that all sessions must be cancelled within 24 hours or I will be charged a non refundable $50 cancelation fee. I understand that all charges incurred are my responsibility and will under no circumstance cancel or dispute charges occurred on my credit card ran by OT Studios, Inc. OT Studios does not guarantee reimbursement from insurance. I will be provided a super bill after every treatment session. If I see a billing discrepancy, I will contact OT Studios, Inc billing department to further discuss.

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    Please note this information will be kept confidential and used solely for billing purposes by OT Studios, Inc. You will be billed weekly for your child’s therapy.