A to Z Pediatric Therapy and ABA to Z are currently in-network with AETNA, BCBS, and some CIGNA plans, and accepts SSI Medicaid and the Katie Beckett Deeming Waiver A to Z/ABA to Z are out-of-network with other insurance companies and Medicaid programs at this time and are considered out-of-network providers.

Until coverage rates can be verified for my specific plan, A to Z/ABA to Z will take payment at the time of service for the contracted rate for in-network coverage or the private pay rate for out-of-network/GAP in-network coverage.

In the case of any overpayments, A to Z/ABA to Z will apply them to future service dates or issue reimbursement as appropriate once claims have finalized.

I will report any changes in insurance coverage immediately to ensure accurate billing and prevent any service interruption. Any failure to notify of coverage may result in unexpected patient costs.

I agree to accept liability for services rendered. This includes late cancel fees, no show fees, and any additional costs (e.g. attendance at meetings, consultation, participation in groups, etc.).

Claims for therapy services will be filed with my insurance company and/or Medicaid, when applicable, for reimbursement. I will then be invoiced on a monthly basis for any outstanding balance and/or any additional charges incurred each month. Payment of my outstanding balance will be due upon receipt. Any balances open for more than 30 days will accrue a 10% late fee for each 30 days past due.

I understand that I am financially responsible for all services provided by A to Z Pediatric Therapy/ABA to Z, LLC. I understand that I may receive an invoice for services rendered. I agree to pay the balance in full upon receipt of the invoice.

By signing this form, I certify:

• That I have read or had this form read and/or had this form explained to me.
• That I fully understand its contents.
• That I have been given ample opportunity to ask questions and that any questions have been answered to my satisfaction.