Authorization to Disclose Protected Health Information (PHI)

This authorization permits Access to Coverage to communicate with the insurance company and the patient’s therapist regarding Single Case Agreements (SCA) and related matters to facilitate in-network rate coverage for out-of-network therapists.

I authorize the disclosure of the following protected health information: • Patient identification details (name, DOB, address). Therapy session notes and billing information relevant to the SCA. Any other records necessary to process the SCA.

Recipient of Information:
Access to Coverage
Contact Information:
Usher Parnes
Phone: 848-525-0066
Fax: 800-342-2313
Email: cs@accesstocoverage.com

All communication regarding SCAs, including call-back request and correspondence, must be directed to Access to Coverage.

*Attach photo of your insurance card:

1. I may revoke this authorization at any time by providing written notice to Access to Coverage, except to the extent that action has already been taken based on this authorization.
2. Information disclosed under this authorization may be re-disclosed by the recipient and may no longer be protected by HIPAA.
3. My treatment, payment, enrollment, or eligibility for benefits is not conditioned on my signing this authorization.

BACKGROUND: A. The Client is of the opinion that the Contractor has the necessar qualifications, experience, and abilities to provide services to the Client. B. The Contractor is agreeable to providing such services to the Client on the terms and conditions set out in this Agreement.

IN CONSIDERATION OF: The matters described above and of the mutual benefits and obligations set forth in this Agreement, the receipt and sufficiency of which consideration is hereby acknowledged, the Client and the Contractor (individually the "Party" and collectively the "Parties" to this Agreement) agree as follows:

TERM OF AGREEMENT: The term of this Agreement (the "Term") will begin on the date of this Agreement and will remain in full force and effect until the completion of the Services, subject to earlier termination as provided in this Agreement. The Term of this Agreement may be extended by mutual written agreement of the Parties.

COMPENSATION: For the services rendered by the Contractor as required by this Agreement, the Client will provide compensation (the "Compensation") to the Contractor as follows:

1. A $100 application fee (nonrefundable), due upon submission of the HIPAA form and completed application.

2. Upon confirmation of approved in-network reimbursement for therapy services:

Tier 1: For approved total coverage amounts up to $9,999, a $500 fee (in addition to the application fee) will be charged.

Tier 2: For approved total coverage amounts of $10,000 or more, a $1,000 fee (in addition to the application fee) will be charged.

3. The Client will provide credit card authorization after the initial review and confirmation of benefits. Upon confirmation of the approved reimbursement amount, the Contractor will charge the card on file based on the applicable tier (Tier 1 or Tier 2). Co-pays are not factored into the total coverage amount.

4. Alternatively, the Client may choose to pay the full $1,000 fee via Zelle, bank transfer, or check at the time of benefit confirmation. If the approved total coverage amount is less than $10,000, the Contractor will reimburse $500 to the original payment method.

CHARGEBACK PROTECTION: The Client acknowledges that by signing this Agreement, they consent to all fees and charges as outlined. Any attempt to initiate a chargeback will require the Client to provide documentation supporting the dispute. The Contractor reserves the right to pursue legal remedies if a chargeback is initiated without valid grounds.

Zelle: Transfer to: cs@accesstocoverage.com
Check: Payable to: Access to Coverage Mail to: 2 Grant Ave, Lakewood NJ 08701 Or send a photo of
the front and back of the check to: cs@accesstocoverage.com
Bank Transfer: Chase Bank - Email cs@accesstocoverage.com for transfer information.

CAPACITY/INDEPENDENT CONTRACTOR: In providing the Services under this Agreement, it is expressly agreed that the Contractor is acting as an independent contractor and not as an employee. The Contractor and the Client acknowledge that this Agreement does not create a partnership or joint venture between them and is exclusively a contract for service ENTIRE AGREEMENT: It is agreed that there is no representation, warranty, collateral agreement, or condition affecting this Agreement except as expressly provided in this Agreement.

IN WITNESS WHEREOF, the Parties have duly affixed their signatures under hand and seal on this