I hereby authorize my insurance benefits to be paid directly to TCBT and I understand that I am financially responsible for non-covered services. I also authorize TCBT to release any information required to process the insurance claim.
I understand that estimated co-pays to TCBT are now due on a monthly basis. Further, I am aware that there may be a portion of service charges that are not covered by my insurance and in such case, I am responsible for the remainder of the balance owed. If I have a balance on my account, and I have not made a payment, I will continue to receive a monthly statement. My account cannot be more than 3 months behind at any time. If it should become more than 3 months behind, TCBT reserves the right to suspend or discontinue services at that time.
In order to fulfill the requirement of paying estimated co-pay amounts, I would prefer to
(check one box below):
I hereby authorize TCBT to charge me the private pay rates listed for ABA services for my child(ren). The private pay rate provided by a Board Certified Behavior Analyst (BCBA) is $80.00 per hour. The rate for a Registered Behavior Technician (RBT) is $30.00 an hour.
I agree to remit payments to TCBT via automatic credit card payments. I also authorize TCBT to keep my signature on file and to charge payments to the card listed below.
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Credit Card number
Expiration Date
CVV (3 digit code on the back)
Zip Code for Credit Card billing address
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Printed name of responsible party/card holder
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Signature of responsible party/card holder
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By signing below, I am stating that I have read and am in agreement with the financial information listed above and understand that this is an agreement between Tri-Cities Behavioral Therapy, as provider and creditor, and the patient (patient’s parent if the child is a minor). By executing this agreement, you, patient or parent, are agreeing to pay for all services that are received as stated above.
