Initial Service Intake Request

If the child is under the parents insurance plan please fill out information below for the subsciber of the child's insurance plan.

If the child's plan is their own and not apart of a family plan please fill out subcriber sections with the childs information.

Consent to Collect and Exchange Personal Information

Purpose

Personal information that we collect and disclose about you, and if applicable, is used by the insurer, and/or plan administrator of your group benefits plan, its affiliates and their service provider(s) for the purposes of assessing eligibility for your claims, underwriting, investigating, auditing and otherwise administering the group benefits plan, including the investigation of fraud and / or plan abuse and for internal data management and data analytical purposes.

Authorization and Consent

I authorize my healthcare provider to collect, use and disclose personal information concerning any claims submitted on my behalf with the insurer and/or plan administrator and their service provider(s) for the above purposes. 

I authorize such insurer and / or plan administrator and their service provider(s) to:

• Use my personal information for the above purposes.

• Exchange personal information with any individual or organization, including healthcare professionals, investigative agencies, insurers and reinsurers, and administrators of government benefits, or other benefits programs, other organizations, or service providers working with such insurer and/or plan administrator or any of the foregoing, when relevant for the above purposes.

•Where applicable exchange personal information concerning any claims with any assignee of benefits payable and exchange personal information for the above purposes electronically or in any other manner. 

I understand that personal information may be subject to disclosure to those authorized under applicable law.

I agree that a photocopy or electronic version of this authorization shall be as valid as the original, and may remain in effect for the continued administration of the group benefits plan.

In the event there is suspicion and/or evidence of fraud and/or plan abuse concerning any claims submitted, I acknowledge and agree that the insurer and/or plan administrator and their service provider(s) may use and disclose relevant personal information to any relevant organization including law enforcement bodies, regulatory bodies, government organizations, medical suppliers and other insurers, and where applicable my employer or benefit plan sponsor, for the purposes of investigation and prevention of fraud and/or benefit plan abuse. I understand that the submission of fraudulent claims is a criminal offence. 

If there is an overpayment, I authorize the recovery of the full amount of the overpayment from any amount payable under the group benefits plan, and the exchange of personal information with other persons or organizations, including credit agencies and, where applicable, my benefit plan sponsor, for that purpose.

If the patient is a person other than myself, I confirm that the patient has given their consent to provide their personal information for the healthcare provider and the insurer and/or plan administrator and their service provider(s) to use and disclose their personal information as set out above.

Benefit Assignment Form

I hereby assign benefits payable for the eligible claims to the healthcare provider responsible for submitting my claims electronically to the group benefits plan and I authorize the insurer/plan administrator to issue payment directly to such provider. In the event my claim(s) are declined by the insurer/plan administrator, I understand that I remain responsible for payment to the healthcare provider for any services rendered and/ or supplies provided.

I acknowledge and agree that the insurer/plan administrator is under no obligation to accept this benefit assignment form, that any benefit payment made in accordance with this benefit assignment form will discharge the insurer/plan administrator of its obligations with respect to that benefit payment, and that in the event the benefit payment is made to me, the insurer/plan administrator will also be discharged of its obligation with respect to that benefit payment.

I understand that this assignment will apply to all eligible claims submitted electronically by my healthcare provider and that I may revoke it at any time by providing written notice to the insurer/plan administrator.

If I am a spouse or dependent, I confirm that I am authorized by the plan member to execute an assignment of benefit payments to the healthcare provider 

Parents utilizing scholarship funding are responsible for ensuring invoices are submitted to their scholarship portal and approved for payment within the required timelines.

Step Up Scholarship Billing & Financial Policy

Spectrum Success Therapy Inc. provides Applied Behavior Analysis (ABA) therapy services that may be funded through the Step Up for Students Scholarship Program. The following policies explain how services are scheduled, billed, and funded.

Service Rates

• ABA Direct Therapy: $60 per hour
• ABA Supervision (BCBA/BCaBA Clinical Oversight): $120 per hour

Minimum Service Commitment
To maintain treatment consistency and clinical progress, the following minimum service levels apply:

• 5 hours per week of direct ABA therapy
• 1 hour per month of clinical supervision by a BCBA or BCaBA

Scholarship Fund Reservation

Parents/Guardians are responsible for reserving scholarship funds through the Step Up portal prior to the start of each service month.

Spectrum Success Therapy Inc. does not have access to student scholarship accounts and cannot view account balances. Parents must monitor their child’s account to ensure sufficient funds are available.

If scholarship funds are not reserved or are insufficient, services may be delayed, reduced, or temporarily paused until funding is confirmed.

Expected Monthly Scholarship Reservation

Parents should reserve approximately $950 per month in the Step Up portal to support their child's ABA therapy services throughout the academic year.

Actual billing will reflect services delivered.

Billing Process
Services are billed after services are rendered at the end of each month based on the actual hours provided.

Once services have been billed through the Step Up portal, parents/guardians must approve and release the funds in their Step Up account for payment to be issued.

If funds reserved exceed the amount billed, the remaining balance will be returned to the scholarship account by the Step Up system.

Parent Financial Responsibility
Due to the individualized needs of each child, therapy hours may change based on:

• treatment goals
• behavioral needs
• skill development
• clinical progress

Because of these variables, scholarship funds may not cover the entire academic year.

Any portion of services not covered by available scholarship funds will be invoiced directly to the parent/guardian at the provider’s standard rates.

Failure to reserve or release scholarship funds does not remove the parent’s financial responsibility for services rendered.

Attendance Policy
ABA therapy sessions are scheduled specifically for your child and require staff scheduling in advance.

Consistent attendance is necessary for effective treatment.

Parents/Guardians must provide at least 24 hours notice for any cancellation.

Sessions cancelled with less than 24 hours notice or missed without notice may be considered non-billable to the scholarship program and may be billed directly to the parent/guardian.

Service Schedule Changes
Changes to a child’s therapy schedule may occur due to:

• clinical recommendations
• staff availability
• school or daycare schedule changes
• changes in treatment needs

Spectrum Success Therapy Inc. will communicate any recommended schedule adjustments with the parent/guardian.

Service Discontinuation
Parents/Guardians who wish to discontinue ABA services must provide at least 14 days written notice.

This notice period allows time to:

• transition services appropriately
• adjust staff schedules
• finalize scholarship billing

If services are discontinued without adequate notice, the parent/guardian may remain responsible for services already scheduled or scholarship funds already reserved during that period.

Parent Responsibility for Scholarship Account

Parents/Guardians are responsible for:

• monitoring scholarship account balances
• reserving monthly funds in the Step Up portal
• approving and releasing funds once services are billed
• notifying Spectrum Success Therapy Inc. if scholarship funds become exhausted

Failure to notify the provider of insufficient scholarship funds may result in personal financial responsibility for services rendered. 

Private Pay Services Notice

You have selected Private Pay (Self-Pay) as the funding source for ABA services.

Private Pay means that Spectrum Success Therapy Inc. will not bill insurance or any third-party payer for services provided. The parent or legal guardian assumes full financial responsibility for all services rendered.

Private Pay services may be selected when:

• The family chooses not to use insurance benefits
• Insurance does not cover ABA services
• Services requested are not covered by the funding source
• Services are being initiated while insurance authorization is pending

Private pay rates may differ from insurance contracted rates. Insurance reimbursement rates are determined by individual payer contracts and do not reflect the standard private pay fee schedule of Spectrum Success Therapy Inc.

Private Pay Fee Schedule

The current private pay rates for services are:

• ABA Direct Therapy (RBT): $80 per hour
• BCBA Supervision / Treatment Modification: $120 per hour
• Parent Training: $120 per hour
• Assessments and Treatment Planning: $120 per hour
• Services are billed based on the actual time spent providing services.

Payment Policy
Payment for private pay services is due according to the clinic’s billing policy.

Parents may be required to maintain a credit or debit card on file for payment processing.

Invoices may be issued periodically based on services rendered. Failure to maintain payment may result in temporary suspension of services until the balance is resolved.

Insurance Reimbursement Disclaimer
If a family elects to receive services on a private pay basis, Spectrum Success Therapy Inc. cannot guarantee reimbursement from any insurance company should the parent later choose to independently submit claims.

Some insurance companies do not reimburse services that were knowingly provided outside of the plan’s authorization process.

Good Faith Estimate Notice
Under federal law, patients who do not use insurance have the right to receive a Good Faith Estimate of the expected cost of services.

Upon request, Spectrum Success Therapy Inc. will provide an estimate of anticipated service costs based on the recommended treatment plan.

Actual costs may vary depending on the number of hours of services delivered and clinical recommendations.

Private Pay Agreement
By selecting Private Pay as the funding source, I acknowledge and agree that:

• I am choosing to receive services without billing insurance.
• I am financially responsible for all services provided.
• I understand the fee schedule for services.
• I understand that insurance reimbursement is not guaranteed 

Private pay services cannot be retroactively submitted to insurance for reimbursement once services have been provided under a self-pay agreement.