Insurance Authorization Form – Pediatric Therapy Services

HIPAA- Insurance Authorization and Assignment of Benefits

Office Location*
Please select your correct location for each form.
I hereby authorize Pediatric Therapy Services, Inc. to furnish all information to insurance carriers and/or Medicaid concerning the patient's diagnosis and or treatments. I hereby assign to PTS, Inc. (providers) all payments for therapy and related services rendered to my dependents.
Patient's First Name*
Patient's Last Name*
Should the insurance company send payment directly to me, I will endorse said check over to Pediatric Therapy Services, Inc.
Initial*
I understand that I am responsible for any amount not covered by insurance: this includes any course of treatment that is not a covered benefit, including DME products.
Initial*
I understand that I am responsible for notifying Pediatric Therapy Services, Inc. of any changes in my insurance coverage.
Initial*
If I am delinquent in updating this information and charges are denied, I understand that I am responsible for these charges.
Initial*
I understand that I may be charged 1.5% interest rate per month on any unpaid balance and that I am responsible for any costs incurred in collection of said balance should that become necessary.
Initial*
I understand that I will be charged a $25 fee for “No Show” appointments.
Initial*
I authorize Pediatric Therapy Services, Inc. to initiate a complaint to the Insurance commissioner for any reason on my behalf.
Initial*
I give my consent for Pediatric Therapy Services, Inc. to appeal claims to my insurance company on my behalf.
Initial*
I give my consent for Pediatric Therapy Services, Inc. to appeal authorizations to my insurance company on my behalf.
Initial*
My signature below indicates that I am the legal guardian of this patient and that I understand and accept this policy.
First name*
Last name*
Relationship to patient:*
Signature*
Email*
Date*
Month
Day
Year

HIPAA- Insurance Authorization and Assignment of Benefits

READY FOR A FUN THERAPY ENVIRONMENT,
THAT TRULY CARES ABOUT YOUR CHILD AND YOUR FAMILY?

Quality Therapy Specifically
For Children

About PTS

Contact Us

Services

Quality Therapy Specifically For Children

About PTS

Contact Us

HIPAA- Insurance Authorization and Assignment of Benefits

READY FOR A FUN THERAPY ENVIRONMENT, THAT TRULY CARES ABOUT YOUR CHILD AND YOUR FAMILY?

Quality Therapy Specifically For Children

About PTS

Contact Us

Services

Quality Therapy Specifically For Children

About PTS

Contact Us

READY FOR A FUN THERAPY ENVIRONMENT,
THAT TRULY CARES ABOUT YOUR CHILD AND YOUR FAMILY?

Quality Therapy Specifically
For Children