My signature below confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Information Portability and Accountability Act of 1996 (HIPAA). I acknowledge that I have been provided with the clinic’s Notice of Privacy Practices that describe how my health information is used and shared. I understand that the clinic reserves the right to change this notice at any time. I may obtain a current copy by contacting the clinic or the billing office.

Our organization may contact you to remind you of any appointments, health care treatment options, billing concerns, or other health services that may be of interest to you.

Services to be Provided
A Chance to Grow will provide services for the client in accordance with the orders provided by the client’s physician. It is understood that licensed providers employed by A Chance To Grow will complete the services provided. The responsible party gives permission for the client to receive services provided by A Chance To Grow.

Insurance Benefits
A Chance To Grow will verify the client’s benefits, file the claims for services provided with the insurance carrier, and notify the responsible party of their financial responsibility. The responsible party understands that the verification of benefits and authorization is not a guarantee of payment and that they are responsible for all charges not paid by the insurance company.

Assignment of Insurance Benefits
The responsible party authorizes any insurance carrier that provides insurance coverage for the client, to make direct payments to A Chance To Grow for any insurance based services rendered. The responsible party will accurately inform A Chance To Grow of the client’s insurance coverage and provide information regarding coverage changes within 5 working days of the change.

Release of Information for Reimbursement
The responsible party authorizes the release of information pertaining to the client’s diagnosis and course of treatment to A Chance To Grow by the client’s physician and any other service providers involved in the client’s care. The responsible party also authorizes the release of information to the client’s physician and any other agencies related to reimbursement issues.

I give permission to A Chance To Grow to release information to my insurance company and bill for services on my behalf. I understand that authorization and verification of benefits is not a guarantee of payment and that I am responsible for any charges not covered by insurance.

I, the undersigned, hereby agree and give my consent to the practice to administer such treatment and care as is prescribed and considered therapeutically necessary on the basis of findings during the course of treatment. I also authorize the practice to furnish information to insurance carriers concerning this treatment and I hereby assign all payment for the services rendered. The information provided is accurate to the best of my knowledge.