PURPOSE OF DISCLOSURE

The patient authorizes Access to Coverage to act as their Authorized Representative for purposes of communicating with insurance carriers, requesting information, submitting documentation, and coordinating coverage and authorization matters.

HIPAA MINIMUM NECESSARY LANGUAGE

Access to Coverage will request, use, and disclose only the minimum necessary protected health information required to perform authorized insurance advocacy services.

DISCLOSURE AUTHORIZATION:

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: 732-475-2111
Fax: 800-342-2313
Email: cs@accesstocoverage.com

CLARIFICATION

The patient authorizes insurance carriers to communicate directly with Access to Coverage regarding the matters described in this authorization.

This authorization permits communication and administrative representation only and does not assign insurance benefits, transfer payment rights, or authorize Access to Coverage to receive insurance reimbursements.

*Attach photo of your insurance card:

This authorization shall remain valid for two (2) years from the date signed or until
completion of insurance advocacy services, whichever occurs later, unless revoked earlier in writing.

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.
4. This authorization may be revoked at any time by submitting written notice via email or mail to Access to Coverage, except to the extent action has already been taken based on this authorization.
5. This authorization may be revoked at any time by submitting written notice via email or mailto Access to Coverage, except to the extent action has already been taken based on thisauthorization.

The patient authorizes communication via email, electronic transmission, and fax for purposes related to insurance advocacy and coverage coordination services.

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:

SERVICES PROVIDED

Insurance Advocacy Services
• Insurance advocacy and coordination services
• Claims and documentation coordination assistance
• Assistance in pursuing insurance coverage or reimbursement consideration for out-ofnetwork therapy services

No Guarantee of Outcome
Contractor provides administrative advocacy services only and does not guarantee
insurance approval, authorization, reimbursement, or payment. All determinations are made solely by the insurance carrier or plan administrator.

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.

Fees for Services

Application & Intake Fee — $150 (Non-Refundable)
This fee covers administrative intake, case review, document preparation, and initiation of advocacy services. The fee is earned upon engagement and is non-refundable regardless of outcome.

Advocacy Completion Fee — $1,000
If the insurance carrier authorizes coverage, grants a network exception, or otherwise allows reimbursement consideration following Contractor’s advocacy e]orts, a completion fee becomes due.

This fee compensates Contractor for administrative coordination, insurer communications, documentation preparation, and implementation support.
Payment is for services rendered and not for a guaranteed outcome.

Definition of Benefit Confirmation

“Benefit Confirmation” or “Approval” means confirmation by the insurance carrier of authorization or eligibility for in-network reimbursement consideration and does not guarantee claim payment or reimbursement amounts.

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.

Administrative Services Only
Contractor is not a healthcare provider and does not provide medical, clinical,
psychotherapy, or legal services. Contractor does not submit claims under its own National Provider Identifier (NPI).

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.

Regulatory Compliance
The Parties intend compliance with all applicable federal and state healthcare laws,
including Medicare and Medicaid regulations and the Federal Anti-Kickback Statute. Fees compensate Contractor solely for administrative services and are not intended to induce referrals or influence coverage determinations.

Client Responsibilities
Client agrees to provide accurate and complete information. Contractor is not responsible for insurance denials, delays, or adverse determinations resulting from insurer policies, provider billing practices, or inaccurate information supplied by Client or third parties.

NO ASSIGNMENT OF BENEFITS
Contractor does not receive insurance reimbursements and is not an assignee of insurance benefits. All insurance payments remain payable solely to the Client and/or treating provider.

Limitation of Liability
Contractor shall not be liable for insurance carrier decisions, claim denials,
reimbursement amounts, or processing delays. Contractor’s total liability under this
Agreement shall not exceed the total fees paid under this Agreement.

GOVERNING LAW
This Agreement shall be governed by the laws of the State of New Jersey. Venue for any dispute shall be Ocean County, New Jersey.

AI / TECHNOLOGY DISCLOSURE
Contractor may utilize secure technology platforms and automated systems, including artificial-intelligence-assisted tools, to support administrative processing while maintaining confidentiality safeguards.

Important Note: If there are other members listed on the policy or if a Primary Care Provider (PCP) is associated with your insurance, they may receive information regarding the SCA (e.g., approvals, denials, or mental health details).

The treating therapist remains solely responsible for clinical services, diagnosis, treatment decisions, and billing/coding accuracy. Access to Coverage provides administrative assistance only.

Diagnosis Codes:

CPT Billing Codes:

CLIENT'S REASON FOR CHOOSING THIS THERAPIST

Please explain why you prefer or require this therapist instead of an in-network provider.

• Consider including:
• Specialized care (e.g., trauma therapy, DBT, EMDR).
• Cultural or linguistic compatibility.
• Established therapeutic relationship and progress.

AUTHORIZATION FOR REPRESENTATION

• Assist in submitting documentation and requests to my insurance carrier related to out-of-network coverage consideration (including Single Case Agreements / gap exceptions when applicable).
• Communicate with my insurance carrier to request information, coordinate next steps, and follow up on the status of my request.
• Coordinate with my treating therapist for supporting documentation, and forward provider-reviewed clinical support materials when needed.

Administrative Advocacy Only / No Guarantee
Access to Coverage provides administrative insurance advocacy services only and does not guarantee approval, authorization, reimbursement, or coverage outcomes. All determinations are made solely by the insurance carrier or plan administrator.

NO ASSIGNMENT OF BENEFITS

This authorization permits administrative representation only and does not assign
insurance benefits or transfer payment rights to Access to Coverage.

I appoint Access to Coverage as my Authorized Representative for purposes of
communicating with insurance carriers, requesting information, submitting
documentation, and coordinating insurance advocacy services related to this request.

NEXT STEPS

Once this form is completed, it will be automatically forwarded to your treating therapist at the email provided above so the therapist may supply supporting documentation as needed. Access to Coverage will coordinate follow-up with the insurance carrier and may request additional documents from the client and therapist.

MEDICARE / MEDICAID COMPLIANCE LANGUAGE
Any fees paid to Access to Coverage compensate administrative advocacy services only and are not payments for patient referrals, insurance approvals, or federally reimbursable services.

Administrative Advocacy Services Only
Access to Coverage provides administrative insurance advocacy and coordination services only. Access to Coverage does not guarantee approval, authorization, reimbursement, or coverage outcomes. All determinations are made solely by the insurance carrier or plan administrator.

Diagnosis Codes:

CPT Billing Codes:

BILLING ASSISTANCE LIMITATION
If billing assistance is provided, Access to Coverage acts solely as an administrative
facilitator. The therapist retains full responsibility for claim accuracy, coding, submission compliance, and adherence to payer requirements.

NO ASSIGNMENT OF BENEFITS
Access to Coverage does not receive insurance reimbursements and is not an assignee of insurance benefits.

JUSTIFICATION FOR COVERAGE OF OUT-OF-NETWORK THERAPIST

Provide the following details to support the case for ongoing treatment with the current therapist:

 

THERAPIST AUTHORIZATION

Provide the following details to support the case for ongoing treatment with the current therapist:

Role of Access to Coverage
Access to Coverage is not a healthcare provider and does not render clinical services. Access to Coverage does not submit claims under its own National Provider Identifier (NPI). The treating therapist remains solely responsible for diagnosis, treatment decisions, documentation, coding accuracy, and billing compliance.

THERAPIST PAYMENT SAFEGUARD
Therapist acknowledges that any payment made to Access to Coverage is solely for
administrative and advocacy assistance and is not contingent upon insurance approval, reimbursement, or claim payment.

ADD AI / TECHNOLOGY DISCLOSURE
Access to Coverage may utilize secure technology platforms and automated systems to assist with document preparation and administrative processing while maintaining confidentiality safeguards.

ADDITIONAL NOTES

Important: Access to Coverage will not make decisions on your behalf without your explicit consent.

Access to Coverage may discontinue services if required documentation is not provided or if continued representation would violate applicable laws or payer requirements.