The information stated above, to the best of my knowledge, is correct and complete. I authorize Elite Occupational Therapy Services LLC and/or their billing service to bill my insurance for any/all services rendered on the person listed above. I also allow my insurance to send payments directly to Elite Occupational Therapy Services LLC. I understand that I am responsible for any co-payments and/or deductibles not covered by my insurance. If for any reason a collection agency is required to collect outstanding funds, I understand that I am responsible for collection fees as well. I authorize Elite Occupational Therapy Services LLC to release all necessary information to my insurance company. The below signature releases any/all medical records past or present to Elite Occupational Therapy Services LLC from other providers. In accordance with NRS 5 629.051, I understand all medical records on the above patient may be destroyed after their 23rd birthday. By signing below I am stating that I have no question regarding this section.