Psychological Intake Agreement Form

Dear Valued Family,

Thank you for selecting the Arizona Institute for Autism, LLC to help you meet the needs of your child. We appreciate you for having selected us to work with your child and family.

This packet of information will help inform you about Arizona Institute for Autism, LLC policies and procedures, and will allow you time to gather information prior to your intake appointment.

Thank you for the trust that you are placing in us to assist you and your family. We understand that some of these forms may be challenging, time-consuming, and in some places redundant.

We want you to know that the more information that we have the better able we will be to assist you and your family. If at any time in this process you have any questions please contact us.

We look forward to meeting you and your child. 

Sincerely,

Rula Diab, Clinical Director

M.Ed, BCBA, LBA 

At the Arizona Institute for Autism LLC our board certified trained providers work one-on-one with each child closely monitoring emotional responses in order to match the difficulty of the material and method of instruction to the child’s ability level and rate of learning. All our providers hold at least a doctotral degree or have equivalent extensive training in Clinical Psycology specifically in research-supported treatments for autism spectrum disorders.

For Clinical Psychological evaluations, our process includes a combination of a clinical interview, completion of written questionnaires, and use of a variety of standardized measures in two or more one-on-one appointments with your child or adolescent.

Depending upon the individual concerns and questions to be answered by the evaluation, testing may include measures of:

• Cognitive Ability
• Academic Achievement and Learning Progress
• Attention and Executive Functioning
• Visual and Auditory Information Processing
• Problem Solving Strategies
• Motor and Visual Perceptual Abilities
• Behavioral and Emotional Functioning

Welcome to our practice where we are committed to providing Psychological evaluations. As part of our dedication to supporting patients, we offer comprehensive information packets that include essential details and assessment tools intended to deliver precise and prompt diagnoses.

By taking into consideration the specific needs of each person, we are able to create customized diagnostic reports and care plans that support growth and progress.

We are excited about the opportunity to work together with you to provide optimal support for both you and your loved one.

This document describes the nature of the agreement for professional services, the agreed upon limits of those services, and the rights and protections afforded under the Psychologist Board’s Guidelines. I will receive a copy of this document to retain for my records. All fees for services and payment arrangements will be reviewed separately.

1. I, the undersigned (parent/Legal guardian), hereby agree to have my child participate in psychological intake services through Arizona Institute For Autism, LLC/ABA Clinic Management, LLC.for the purpose of understanding and assessing my child’s psychological, emotional, cognitive and/or behavioral concerns to determine the presence of absence of conditions such as Autism Spectrum Disorder (ASD), or Attention-Deficit/Hyperactivity Disorder (ADHD), develop a diagnostic report to address these concerns and provide support, guidance to improve my child’s mental health and well-being.
2. I agree to have my child participate in services that may include, but are not limited, to assessment, evaluation, diagnosis, and referral treatment that meets the child's needs.
3. I understand that the assessment process may include the following process; initial interviews to gather information about my child’s personal and medical history, standardized psychological testing, questionnaires, observation and assessments to better understand my child’s cognitive, emotional, and behavioral functioning, and also consultation and collaboration with other professionals and sources to gather additional information if necessary.The assessment may take place over multiple sessions.
4. I understand that I will receive feedback and a written report summarizing the assessment findings. This report will be used to guide any recommendations for further evaluation or treatment.
5. I acknowledge that all information obtained during this assessment process will be kept confidential. Release of information to third parties shall only occur upon obtaining a signed agreement from a client’s parents/legal guardians. However, there are certain situations in which confidentiality may be legally breached, such as if there is a risk of harm to myself or others or if required by court order.
6. I understand that I have certain rights and responsibilities as a patient, including but not limited to: The right to ask questions about my services and seek clarification about any aspect of the assessment process before signing this document, seek a second opinion, the responsibility to attend scheduled appointments and inform my provider of any changes in my contact information, the right to terminate services at any time, and the responsibility to provide reasonable notice if I choose to do so, although doing so may limit the ability to provide an accurate diagnosis or treatment recommendations.
7. I am also aware that Arizona Institute for Autism are legally required to report suspected occurrences of child abuse or neglect or if I or my child present clear and present danger to ourselves or to others.
8. I understand that under the code of ethical conduct developed by the Psychologist Board, Arizona Institute For Autism, LLC/ABA Clinic Management, LLC. staff and providers should maintain professional relationship and confidentiality for patient's information unless a consent form is obtained.
9. I understand that parents/legal guardians should give advance notification for cancellation 48 hours. I acknowledge that there may be a cancellation and no-show policy, and I will adhere to it as discussed by my provider.
 10. I understand that I am responsible for payment of fees associated with these services. The fee structure and payment methods will be discussed with the Arizona Institute for Autism and must be paid in full prior to service.
 11. I understand that I can be contacted via Phone, Text, or Email to communicate with matters related to assessment process and clinical outcomes.I understand that electronic communication, such as emails or text messages, may not be secure. I will use these methods of communication at my own risk.
 12. I understand that In the event of  a psychological crisis or emergency, I will seek immediate assistance from a qualified mental health professional or contact emergency services.
13. I hereby assign and request payment directly to Arizona Institute For Autism LLC/ ABA Clinic Management LLC of any insurance or other authorized health benefits, and to release any information required to the insurance company for consideration of payment for services.
14. I acknowledge the importance of maintaining professional boundaries and agree to adhere to the therapeutic relationship's ethical guidelines.
15. I understand that Arizona Institute for Autism may terminate our professional relationship if it is determined that my needs exceed their scope of practice or if it is in my best interest to be referred to another mental health professional.

The Arizona Institute for Autism, LLC/ ABA Clinic Management, LLC does not authorize staff of the Psychological department to administer medication of any kind.

By signing below, I understand the Arizona Institute For Autism, LLC/ ABA Clinic Management LLC staff does not administer medication.

This form is used to release your protected health information as required by federal and state privacy laws. Your authorization allows your providers to obtain and release your protected health information to a person or organization that you authorize. You can revoke this authorization at any time by submitting a request in writing to the provider. Revoking this authorization will not affect any action taken prior to receipt of your written request to revoke.

I understand this release is voluntary and applies to all programs and services operated under Arizona Institute For Autism, LLC/ ABA Clinic Management, LLC. I understand that I may revoke this authorization at any time by notifying Arizona Institute For Autism, LLC in writing but if I do, it will not have any effect on any taken before receipt of the revocation.

I, the undersigned, authorize Arizona Institute For Autism/ABA Clinic Management, LLC to release, exchange or request access to the information specified below for the below-named client. I hereby authorize Arizona Institute For Autism, LLC/ABA Clinic Management, LLC to exchange / release / obtain information both verbally and in writing.

Description of information to be exchanged / released / obtained:

●  Education records
●  Medical records
●  Evaluation/assessment/eligibility records
●  Clinical records (including behavior analytic, psychological, physical, occupational, and speech therapies)

Name of third party to exchange information

 

Parent/Guardian Participation: Parent/guardian understands that Arizona Institute For Autism, LLC/ ABA Clinic Management, LLC is a parent participation model. This means that the Parent/Guardian’s participation is mandated during the diagnosis process thr by Arizona Institute For Autism, LLC/ABA Clinic Management, LLC as well as our funding sources.

The Parent/Guardian agrees to participate in the program as requested by the evaluator when clinically necessary or as mandated by the funding source. Please note that Arizona Institute For Autism, LLC/ABA Clinic Management, LLC diagnostic report includes information shared by Parent/Guardian.

I agree to allow Arizona Institute For Autism, LLC/ABA Clinic Management, LLC to contact me in the following methods regarding my Private Health Information (PHI), evaluation, and treatment.

Please review the following:

●  Home Phone
●  Cell Phone
●  Work Phone
●  Alternate Phone
●  Text Message
●  Email
●  Work-Related Purposes
●  Wifi

When contacting Arizona Institute For Autism, LLC. We will make every effort to respond within 24 hours (except for weekends and holidays). If you cannot reach Arizona Institute For Autism, LLC employees and are experiencing an emergency, call 911 or go to the nearest emergency room and ask for the psychiatrist on call.

In order to track your child’s progress more effectively, Arizona Institute For Autism, LLC/ABA Clinic Management will periodically videotape and/or photograph your child during an intervention. The specific purpose of the photographs and/or videos is to enable members of the clinical leadership at Arizona Institute For Autism, LLC/ABA Clinic Management, LLC including directors, clinical management, our staff members’ performance, and to ensure that the quality of our program is constantly maintained and advanced.

Arizona Institute For Autism, LLC/ ABA Clinic Management LLC would appreciate your permission to include videos and/or photographs of your child for the following specific and limited purposes.

Please review the following:

●  Workshop presentations, training other professionals (i.e., school personnel, psychologists, regional center staff).
●  Presentation to parent groups/parent workshops.
●  Presentation of data at conferences.
●  Arizona Institute For Autism published manuals, book chapters, and/or research articles.
●  Arizona Institute For Autism in-house staff training.
●  Arizona Institute For Autism in-house parent training.
●  Arizona Institute For Autism promotional materials (brochures, videos, website, etc.).

By signing below, I give Arizona Institute For Autism/ABA Clinic Management, LLC permission to videotape and/or photograph my child for the purposes detailed above unless stated otherwise.

By signing below, I do not give Arizona Institute For Autism permission to videotape and/or photograph my child for the purposes detailed above unless stated otherwise.

Arizona Institute For Autism, LLC/ABA Clinic Management, LLC intends to foster relationships with patients and their families that thrive on respect, professionalism, and care. Because of this, our desire is that open communication exists between the patients/patient's family and the Arizona Institute For Autism’s team assigned to that consumer. Arizona Institute For Autism desires that families voice concerns with their assigned team as they arise. Assigned staff will make every attempt to validate and address concerns immediately. Should a consumer or their family encounter a situation in which they do not think their concern has been adequately addressed, they may follow the steps below to file a grievance:

Contact the assigned Clinical Manager and voice their concern. If the Clinical Manager is not able to adequately address the concern, continue as follows.
Contact the Clinical Director, Rula Diab at (480) 707-2195 and voice their concern.  Correspondence will be received and addressed as quickly as possible.

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU OR YOUR CHILD MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Arizona Institute For Autism, LLC/ABA Clinic Management, LLC is dedicated to maintaining the privacy of our client’s (the Client”) individually identifiable health information (also called protected health information, or PHI). In conducting our business, we will create records regarding the Client and the treatment and services we provide. We are required by law to maintain the confidentiality of health information that identifies Clients. We also are required by law to provide this notice of our legal duties and the privacy practices that we maintain in our practice concerning Client’s PHI. By federal and state law, we must follow the terms of the Notice of Privacy Practices that we have in effect at the time.

We realize that these laws are complicated, but we must provide you with the following important information:

●  How we may use and disclose a Client’s PHI,
●  Privacy rights in PHI,
●  Our obligations concerning the use and disclosure of PHI.

The terms of this notice apply to all records containing a Client’s PHI that are created or retained by Arizona Institute For Autism, LLC, ABA Clinic AManagement, LLC. We reserve the right to revise or amend this Notice of Privacy Practices. Any revision or amendment to this notice will be effective for all records created or maintained in the past, and for any records that we may create or maintain in the future. Arizona Institute For Autism/ABA Clinic Management will always post a copy of our current Notice in our offices in a visible location, and you may request a copy of our most current Notice at any time.

I. HOW Arizona Institute For Autism/ ABA Clinic Management WILL USE AND DISCLOSE PHI.

Arizona Institute For Autism Behavioral Services Inc. will use and disclose a Client’s PHI for many different reasons. Some of the uses or disclosures will require your prior written authorization; others, however, will not. Below you will find the different categories of our uses and disclosures, with some examples.

A. Uses and Disclosures Related to Treatment, Payment, or Health Care Operations Do Not Require Prior Written Consent.

Arizona Institute For Autism may use and disclose a Client’s PHI without consent for the following reasons: 1. For treatment. Arizona Institute For Autism may disclose PHI to physicians,

psychiatrists, psychologists, behavior interventionists, and other licensed healthcare providers who provide a Client with health care services or are otherwise involved in his or her care. Example: If a psychiatrist is treating a client, Arizona Institute For Autism may disclose PHI to her/him in order to coordinate services.

2. For health care operations. Arizona Institute For Autism may disclose PHI to facilitate

the efficient and correct operation of the services it provides. Examples: Quality control – Arizona Institute For Autism might use PHI in the evaluation of the quality of services that a Client receives or to evaluate the performance of the behavior interventionists who provided these services. Arizona Institute For Autism may also provide PHI to company attorneys, accountants, consultants, and others to make sure that Arizona Institute For Autism follows applicable laws.

3. To obtain payment for treatment. Arizona Institute For Autism may use and disclose PHI to bill and collect payment for the treatment and services Arizona Institute For Autism has provided. Example: We might send PHI to the Client’s Regional Center or insurance company in order to get payment for the services that Arizona Institute For Autism has provided. Arizona Institute For Autism could also provide PHI to business associates that provide services for Arizona Institute For Autism.

4. Other disclosures. Examples: Consent isn’t required if a Client needs emergency

treatment if Arizona Institute For Autism attempts to get consent after treatment is rendered. If Arizona Institute For Autism tries to get consent, however, you are unable to communicate with us, but Arizona Institute For Autism thinks that you would consent to such treatment if you could, Arizona Institute For Autism may disclose PHI.

B. Certain Other Uses and Disclosures Do Not Require Consent. Arizona Institute For Autism may use and/or disclose PHI without consent or authorization for the following reasons:

1. Required by Law. When disclosure is (a) required by federal, state, or local law; judicial, board, or administrative proceedings; or law enforcement; (b) compelled by a party to a proceeding before a court, arbitration panel or an administrative agency pursuant to its lawful authority; (c) required a search warrant lawfully issued to a government law enforcement agency; or (d) compelled by the patient or the patient’s representative pursuant to Arizona Health and Safety Codes or to corresponding federal statutes of regulations, such as the Privacy Rule that requires this Notice.

2. To avoid harm. When disclosure: (a) to law enforcement personnel or persons may be able to prevent or mitigate a serious threat to the health or safety of a person or the public; (b) is compelled or permitted by the fact that the Client is in such mental or emotional condition as to be dangerous to him or herself or the person or property of others, and if Arizona Institute For Autism determines that disclosure is necessary to prevent the threatened danger; (c) is mandated by the Arizona Child Abuse and Neglect Reporting law (for example, if we have a reasonable suspicion of child abuse or neglect); (d) is mandated by the Arizona Elder/Dependent Adult Abuse Reporting law (for example, if we have a reasonable suspicion of elder abuse or dependent adult abuse); and (e) if disclosure is compelled or permitted by the fact that you or your child tells us of a serious/imminent threat of physical violence against a reasonably identifiable victim or victims.

3. For public health activities. When disclosure is for: (a) maintaining vital records, such as births and deaths; (b)preventing or controlling disease, injury or disability, (c) notifying a person regarding potential exposure to a communicable disease; (d) notifying a person regarding a potential risk for spreading or contracting a disease or condition; (d) reporting reactions to drugs or problems with products or devices; or (e) notifying individuals if a product or device they may be using has been recalled.

4. For health oversight activities. Arizona Institute For Autism may disclose PHI to a health oversight agency for activities authorized by law. Oversight activities can include, for example: investigations, inspections, audits, surveys, licensure, and disciplinary actions; civil, administrative, and criminal procedures or actions; or other activities necessary for the government to monitor government programs, compliance with civil rights laws, and the health care system in general.

5. For specific government functions. Examples: Arizona Institute For Autism may disclose PHI of military personnel and veterans under certain circumstances.

6. For Workers’ Compensation purposes. Arizona Institute For Autism may provide PHI in order to comply with Workers’ Compensation laws.

7. Appointment reminders and health-related benefits or services. Arizona Institute For Autism permitted to contact you, without prior authorization, to provide an appointment reminders or information about alternatives or other health-related benefits and services that may be of interest.

C. Certain Uses and Disclosures Require You to Have the Opportunity to Object. 1. Disclosures to family, friends or others. Arizona Institute For Autism may provide PHI
to a family member, friend, or another individual who you indicate as involved in the Client’s care or responsible for the payment of health care, unless you object in whole or in part. Retroactive consent may be obtained in emergency situations.

D. Other Uses and Disclosures Require Your Prior Written Authorization. In any other situation not described in Sections I.A, I.B, and I.C above, Arizona Institute For Autism will

request written authorization before using or disclosing any of the PHI. Even if you have signed an authorization to disclose PHI, you may later revoke that authorization, in writing, to stop any future uses and disclosures (if Arizona Institute For Autism has not taken any action subsequent to the original authorization) of PHI by Arizona Institute For Autism.

II. RIGHTS REGARDING PHI
These are your rights with respect to PHI:

A. The Right to See and Get Copies of PHI. In general, you have the right to see PHI that is in Arizona Institute For Autism possession, or to get copies of it; however, you must request it in writing. If Arizona Institute For Autism does not have the PHI, but Arizona Institute For Autism knows who does, Arizona Institute For Autism will advise you how you can get it. You will receive a response from Arizona Institute For Autism within 30 days of receipt of your written request. Under certain circumstances, Arizona Institute For Autism may deny your request, but Arizona Institute For Autism will give you, in writing, the reasons for the denial. Arizona Institute For Autism will also explain your right to have the denial reviewed. Arizona Institute For Autism may see fit to provide you with a summary or explanation of the PHI, but only if you agree to it, as well as to the cost, in advance.

B. The Right to Request Limits on Uses and Disclosures of PHI. You have the right to ask that Arizona Institute For Autism limits how it uses and discloses PHI. While Arizona Institute For Autism will consider your request, Arizona Institute For Autism is not legally bound to agree. If Arizona Institute For Autism does agree to your request, Arizona Institute For Autism will put those limits in writing and abide by them except in emergency situations. You do not have the right to limit the uses and disclosures that Arizona Institute For Autism is legally required or permitted to make.

It is important that you read the Psycological Financial Agreement carefully, as your signature on this document indicates you have read, understand, and agree to the Financial Policies below. Please ensure that you have reviewed the agreement in addition to cancellation Policy.

 

Please review the following:

●  I understand the credit card on file will be charged within twenty-four (24) hours of scheduled service date.
●  All balances will automatically be charged to your Credit Card on file. 
●  I understand that the Arizona Institute for Autism, LLC and its affiliate ABA Clinic Management, LLC contracts with insurance can or may be subject to change.
●  Before my scheduled appointment, I understand that my account must be paid in full. Unpaid accounts are considered delinquent. No additional appointments will be made for clients with delinquent accounts until they are current. Delinquent accounts
will be turned over to a licensed collection agency; I agree to pay a collection fee equal to 30% of our outstanding balance at the time the account is placed with the collection agency.
● I understand that a 2.5% transaction fee will be added to my monthly invoice if funds are being paid by ESA (Empowerment Scholarship Account).

Fee Schedule

The following fees are not covered by insurance and include the followiwng as proviate pay fee options:

●  Autism Learner Targeted Evaluation $2100.00

● ADHD Learner Targeted Evaluation $2100.00

● ASD/ADHD Learner Targeted Evalution $35000.00

●  Cancellation Fees: $50.00 per session
●  No-Shows: $50.00 per hour, per session

Psychological Session Cancellation

At the Arizona Institute for Autism (AIA), our goal is to provide quality Psychological care to all of our clients in a timely manner. No-shows, late arrivals, and cancellations inconvenience not only our providers but our other clients as well. Please be aware of our policy regarding missed and late sessions.

When a session is booked, you are holding space on our schedule that is no longer available to our other patients. In order to be respectful of your fellow patients, please call the front desk or contact your provider as soon as you know you will not be able to make your appointment.

If cancellation is necessary, we require that you call at least 72 hours in advance. Sessions are in high demand, and your advanced notice will allow another client access to that appointment time. Failure to cancel within 72 hours will result in a fee of $50.00.

How to Cancel Your Psychological Session

If you need to cancel your session, please call or email us between the hours of 8:00 AM-6:00 PM. If necessary, you may leave a detailed voicemail message. We will return your call as soon as possible.

Late Cancellations/No-Shows

A late cancellation is considered "late" when you arrive 15 minutes after your scheduled session. A no-show is when a client misses a session without canceling. In that case, we will charge a client a fee of $50.00/hour for any missed session.

 

Please review the following:

●  I understand that a credit card must be put on file with authorization charges to be made. We accept Visa, Mastercard, Discover, or American Express.
●  I understand bypassing the credit card on files requirement cannot be waived.
●  I understand billing charges (i.e., services rendered, deductibles, co-pays, co-insurance) will be charged within 24 hours of my appointment time.
●  I understand if I choose to place a debit/HSA/flex card on file as a primary form of payment, a secondary true credit card must be put on file as a secondary form of payment in the event your debit/HSA/Flex card does not have sufficient funds.
●  I understand it is my responsibility to update credit card information. In the event, your primary and secondary card is declined, you will be contacted by phone and/or email to obtain active information. New information must be updated within three (3) business days. If information is not obtained within three (3) business days, follow up appointments will be scheduled until this information is obtained and/or recurring appointments already scheduled will be canceled. If multiple attempts have been made to obtain payments and if the balance remains unpaid after fifteen (15) business days, services will be terminated.

Statements

Please review the following:
●  I understand that statements will be sent by request only.
●  I understand that by request only, yearly statements must be requested 30-45 business days ahead of time. Due toEOB/Insurance processing, yearly statements take 30-45 business days to generate and may not be complete if the Arizona Institute for Autism, LLC has not received EOBs.

Private Pay

Please review the following:

●  I understand that it is my responsibility to pay for Psychological services prior to the day of the appointment(s).
●  I understand that my credit card on file will be run manually at the Arizona Institute for Autism, LLC based on the private pay fee schedule.

Splitting Fee Cost among Caregivers

The Arizona Institute for Autism is not responsible for invoicing or billing more than one parent or guardian. It is the parents/guardian’s responsibility to ensure full payment is provided and personally ensure that accurate percentages are contributed by the other caregivers as they have agreed upon. The individual that signs this agreement will be considered the responsible party from whom payment will be required in full.

Payment Plans

Payments plans may be considered and offered on a case-by-case basis, however, all payment plans require a separate contractual agreement. Payment plans are only approved on occasion due to extenuating circumstances and provided as a courtesy. Payment plans may be not considered for outstanding balances already accrued. Payment plans require a credit card on file and will be charged a minimum amount on a specified date until the balance is paid in full. If timelines and contractual agreements are not abided by, the agreement will be immediately considered null and void, defaulting to immediate payment of the entire balance.

In the event a client terminates and/or is discharged from a Psychological service the payment plan is terminated, and the entire balance is required to be paid in full within one (1) week of the client’s last appointment. Furthermore, if payment is not received by the agreed due date, services will be put on hold until the agreed amount or payment is received in full.

Delinquent Accounts

Please review the following:
●  I understand failure to comply with this financial agreement and declining agreement and declining to work with the Arizona Institute for Autism in good faith to resolve the problem will result in a termination of services.
●  Deductibles, co-insurance, and co-pays are required to be paid on the day services are rendered. If payment cannot be made within three (3) business days of rendered services, follow-up and recurring appointments will be canceled until payment can be made. Failure to pay the balance after fifteen (15) business days will result in the termination of services.

Accounts past due ninety (90) days or more are subject to collection and any additional associated fees.

Credit Card on File

Please review the following:

●  I understand that a credit card must be put on file with authorization charges to be made. We accept Visa, Mastercard, Discover, or American Express.
●  I understand bypassing the credit card on files requirement cannot be waived.
●  I understand billing charges (i.e., services rendered, deductibles, co-pays, co-insurance) will be charged within 24 hours

of my appointment time.
●  I understand if I choose to place a debit/HSA/flex card on file as a primary form of payment, a secondary true credit card

must be put on file as a secondary form of payment in the event your debit/HSA/Flex card does not have sufficient funds.
●  I understand it is my responsibility to update credit card information. In the event, your primary and secondary card is declined, you will be contacted by phone and/or email to obtain active information. New information must be updated

within three (3) business days. If information is not obtained within three (3) business days, follow up appointments will be scheduled until this information is obtained and/or recurring appointments already scheduled will be canceled. If multiple attempts have been made to obtain payments and if the balance remains unpaid after fifteen (15) business days, services will be terminated.

Statements

Please review the following:
●  I understand that statements will be sent by request only.
●  I understand that by request only, yearly statements must be requested 30-45 business days ahead of time. Due to EOB/Insurance processing, yearly statements take 30-45 business days to generate and may not be complete if the Arizona Institute for Autism, LLC has not received EOBs.

By signing the financial agreement in the client intake packet, I authorize the Arizona Institute for Autism, LLC to charge my credit card provided herein. I agree to pay for services and understand the terms outlined in the financial agreement and financial consultation.

●  I understand that Arizona Institute for Autism, LLC. will make all reasonable attempts to bill my insurance company first. If my insurance company does not pay for any portion of the services provided, I agree and acknowledge that I am responsible for the outstanding fees and co-pays remaining.
●  I authorize Arizona Institute For Autism, LLC. to release information requested by my insurance company to complete my claim.
●  I authorize payment from the insurance company to be directly sent to Arizona Institute For Autism, LLC. This allows Arizona Institute For Autism, LLC. To file claims on my behalf.