Financial Information Form

Financial Information Form
We appreciate you choosing to come to Beyond The Spectrum, LLC for ABA therapy. Please complete requested below insections:
A. Please select one of or more of the following:

I intend to use any insurance benefits available to pay for the services I receive here. (Please complete E, F, and F of this form.)I decline to use the health insurance I have. (Please select options 4, 5, or 6 below.)I have no health insurance coverage.I intend to use a health savings account (HAS), flexible savings account (FSA), or similar. (Please discuss this with us)I will use a credit card to pay my copays or other fees. (Please discuss this with us.)I will pay by cash or check at each visit.
B. We can submit claims to your health insurance plan or managed care organization (MCO) for you, but you must authorize me to receive any payments the insurer makes. Because I have a contract with your plan, I am “in network” and must charge you only the fee that the insurer and I have agreed to. You will pay me the full fee until your payments reach the yearly deductible of your health insurance. After that, you will pay me only the copayment or “copay” for each time we meet.
C. The use of health insurance to pay for all or part of therapy involves many considerations. You can learn more about these in the handout entitled “What You Should Know about Managed Care and Your Treatment.” The major concerns include these:
- When an insurance company pays for part of your treatment, the company has a right to review your records, limit treatment, and deny claims for payment.
- Not all services may be covered, including phone meetings, video conferencing, and any services the company decides are not “medically necessary”. If you request and agree to services that are not covered, you will be expected to pay for them, and we will sign an additional contract.
- If your insurance changes, you agree to provide me with an update as soon as possible. If you become eligible for additional or different insurance such as Medicare, you must inform Beyond The Spectrum.
- This office will submit claims in a timely manner and will provide an update to you if the insurance company or MCO denies the claim.
D. Please give us this information as it appears on your insurance policies or cards:
Client Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Age of Client
Home Phone Number
Cell Phone Number
Home Street Address
City
State
Zip Code
E: If you are covered under someone else's insurance plan, please provide this information:
Policy Holder's Name
Date of Birth

MonthDayYear
Date
Relationship to the client

SelfSpouseParentOther
If other please specify:
Name of Insurance Company
Health Plan Policy Number
Group Number
FECA Number
Effective Date

MonthDayYear
Date
Reciprocity Number
Phone Number of Plan
Address to send claims
Other information on Card
F. If you or the policy holder (if different from you) have a second kind of health insurance, please fill in the numbers and
Policy Holder's Name
Date of birth

MonthDayYear
Date
Relationship to the client

SelfSpouseParentOther
If other please specify:
Name of Insurance Company
Health Plan Policy Number
Group Number
FECA Number
Effective Date

MonthDayYear
Date
Reciprocity Number
Phone Number of Plan
Address to send claims
G. Release of information and assignment of benefits:
I, the client (or the policy holder), by my signature below authorize the release by this office of any information obtained during evaluations and treatment that is necessary to support and process any insurance claims, determine medical necessity, support any clinical or financial audits, or requests for additional sessions, I hereby assign medical benefits, including those from government sponsored programs and other health plans, to be paid to the clinician or organization above. Medicare regulations may apply.

I understand that I am responsible for all charges, regardless of insurance coverage or other payments. A photocopy of this agreement is to be considered as good as the original.
Client/Guardian or Policy holders Signature

Clear
Printed Name
Date

MonthDayYear
Date
AGREEMENT TO PAY FOR PROFESSIONAL SERVICES
I request that the clinician named below provide professional services to blanks , who is my blank and I agree to pay this clinician's fee per session for these services or any other fees accrued as a result of services received.
I understand and agree that I am responsible for paying the charges for services provided by this clinician to me (or this client although other persons or insurance companies may make payments on my (or this client's) account.

I agree to pay for services provided to me (or the client) up until the time we end the relationship. We will discuss ending. and a date will be agreed to and recorded in this client's medical record; or I will inform the clinician, in person or by certified mail, that I wish to end it. I agree to meet with this clinician at least once before terminating ABA therapy.
Signature of client (or person acting for client)

Clear
Date

MonthDayYear
Date
Printed Name of client (or person acting for client)
Date

MonthDayYear
Date
For clinician only:
I, the clinician, have discussed the financial agreement above with the client (and/or the person acting for the client My observations of the person's behavior and responses give me no reason to believe that this person is able to give information and willing consent.
Should be Empty:

Financial Information Form

D. Please give us this information as it appears on your insurance policies or cards:

E: If you are covered under someone else's insurance plan, please provide this information:

F. If you or the policy holder (if different from you) have a second kind of health insurance, please fill in the numbers and

G. Release of information and assignment of benefits:

AGREEMENT TO PAY FOR PROFESSIONAL SERVICES

For clinician only: