Thank you for choosing Marin Autism Interventions, LLC as your ABA provider. We are committed to providing you with the highest quality ABA therapy. Please read and sign this form to acknowledge your understanding of our patient financial policies.
INDIVIDUAL’S FINANCIAL RESPONSIBILITY
- I understand that I am financially responsible for my health insurance deductible, copays, coinsurance or non-covered services. ** Failure to pay any insurance-related costs is a breech of contract with your insurance company.
- Co-payments, deductibles, and co-insurance are due upon receipt of invoice.
- In the event that my health plan determines a service is “not payable”, I will be responsible for the complete charge and agree to pay the costs of all services provided.
- Patients may incur, and are responsible for payment of additional charges, if applicable. These charges may include:
$25 Charge for returned checks
$25 Charge for missed appointments without 24 hours’ notice
Charges for therapy materials that are damaged or lost by client or family
- If I become uninsured, I agree to pay for therapy services rendered to me at time of service.
- I understand that MAI has a $3,000 maximum on past due accounts. Accounts exceeding this limit will be moved from daily tiered service delivery to a monthly (60-minute) parent training model until the balance is satisfied.
INSURANCE AUTHORIZATION FOR ASSIGNMENT OF BENEFITS
I hereby authorize and direct payment of my medical benefits to Marin Autism Interventions, LLC on my behalf for any services furnished to me by the providers.
AUTHORIZATION TO RELEASE RECORDS
I hereby authorize Marin Autism Interventions, LLC to release to my insurer, governmental agencies, or any other entity financially responsible for my medical care, all information, including diagnosis and the records of any treatment or examination rendered to me needed to substantiate payment for such medical services as well as information required for precertification, authorization or referral to other medical provider.
MEDICAID REQUEST FOR PAYMENT
I understand that Marin Autism Interventions, LLC is a multi-specialty group (MSG) that provides ABA therapy using a "tiered service model" that incorporates the use of RBTs and ABA Tutors (paraprofessionals) under the supervision of a BCBA, LBA. I understand that some Medicaid and Medicaid Managed Care Organizations (MCO) do not reimburse for services performed by non-licensed paraprofessionals in an MSG, even if my primary commercial insurance carrier authorizes the service. MCOs include Wellcare and Passport. I agree to pay all co-pays, deductibles, coinsurance, or other "non-payable" amounts associated with services rendered by the paraprofessional.
With my signature below, I hereby authorize assignment of financial benefits directly to Marin Autism Interventions, LLC and any associated healthcare entities for services rendered as allowable under standard third party contracts.