Please read and sign each section that applies to you.
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.
By signing, you are stating that you have read and are 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 / guardian if the child is a minor). By executing this agreement, you, are agreeing to pay for all services that are received as stated above.
If you would rather print this form and return to us in person or by mail, click on the button below labeled "Printable Forms".
Our address is. Tri-Cities Behavioral Therapy 321 West Walnut Street Box #2 Johnson City, Tennessee 37604
Click (Submit) to finish the form. If you can not continue make sure all required fields with an ( * ) have been filled out. Any missed fields will be highlighted in red to make it easier in finding them.
