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.
Credit Card number
Expiration Date
CVV (3 digit code on the back)
Zip Code for Credit Card billing address
Printed name of responsible party/card holder
Signature of responsible party/card holder
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.
