HIPAA- Insurance Authorization and Assignment of Benefits

  • 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.
  • Should the insurance company send payment directly to me, I will endorse said check over to Pediatric Therapy Services, Inc.
  • 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.
  • I understand that I am responsible for notifying Pediatric Therapy Services, Inc. of any changes in my insurance coverage.
  • If I am delinquent in updating this information and charges are denied, I understand that I am responsible for these charges.
  • 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.
  • I understand that I will be charged a $25 fee for “No Show” appointments.
  • I authorize Pediatric Therapy Services, Inc. to initiate a complaint to the Insurance commissioner for any reason on my behalf.
  • I give my consent for Pediatric Therapy Services, Inc. to appeal claims to my insurance company on my behalf.
  • I give my consent for Pediatric Therapy Services, Inc. to appeal authorizations to my insurance company on my behalf.
  • My signature below indicates that I am the legal guardian of this patient and that I understand and accept this policy.