The information stated above, to the best of my knowledge, is correct and complete. I authorize Elite Occupational Therapy Services and/or their 3rd party billing company to bill my insurance for any/all services rendered on the patient 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. I also agree to allow Elite Occupational Therapy, LLC will share your childs medical record informatin with our 3rd party medical billing associate for medical billing, claims, insurance verification and eligbility purposes only. 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 further questions regarding this section.