ADHD testing is a service that your provider feels is necessary for diagnosing and treatment planning that may not be covered by your insurance carrier. We require a parent or guardian to remain and wait in the lobby for patients 12 and under while the test is in progress.
If the services are not covered by your insurance carrier, you will be responsible for payment of the full amount at the time of service. If the services are covered by your insurance carrier, you will be responsible for the full amount of the applicable copay and/or deductible at the time of the service. You will be billed or credited as needed once the claims process. If the patient is unable to pass the ability portion of the test after 3 attempts, the patient will be required to reschedule another testing appointment. Ifthe patient is unable to pass the ability portion of the test, a self pay $50 fee applies. The abilities test alone does not qualify for insurance billing. Patient responsibility amounts for the testing process will apply to the next testing appointment. If the patient opts to take the at-home test via QbCheck, the patient is responsible for a $250 fee for the self-administration voucher code. The at-home test is not a billable service to insurance companies.
Description of service Qb Ability and QbTest administration QbTest results review and interpretation Self Pay - no insurance
CPT Code 96136 or 96138 96132 or 96130
Iunderstand that my insurance carrier may not pay for the above services. These services are billed in conjunction with an office visit. If my insurance carrier does not cover the services, I agree to be personally and fully responsible for payment. If you have any questions or concerns regarding your insurance carrier's coverage, please contact the customer service phone number listed on your insurance card.
Iacknowledge that I am signing this statement voluntarily, and that it is not being signed under duress or after the services have already been provided. I understand that by signing this form, I will be fully responsible for the total charge(s) for any service not fully paid by an insurance company or otherwise. I agree that I will pay LÉVO this full amount, even though my insurance carrier will not make payment.