On behalf of myself and/or my chiId or children receiving treatment (Patient or Patients), I hereby give my consent to and authorize all treatment that may be advisable or necessary. This above consent shall apply to all sessions now and in the future, unless I revoke this authorization via written certified letter sent to the following address. The effective date of the revocation will be the date the letter is received by TheraCare Managed Care Services, LLC (dba ABA Provider Services).
TheraCare Managed Care Services, LLC
Attn: Managed Care Service Director
116 W. 32nd Street 8th Floor
New York, NY 10001
Furthermore, I will inform this office of any changes to Patient(s) medical history, insurance coverage, telephone number and/or address as they occur and, periodically, verify (with TheraCare office staff) that my Patient information on record is accurate. I certify that this information is true and correct to the best of my knowledge.
I UNDERSTAND AND ACCEPT THAT I AM ULTIMATELY FINANCIALLY RESPONSIBLE FOR ALL CO-PAYMENTS, DEDUCTIBLE AND CO-INSURANCE AMOUNTS AS MAY BE APPLICABLE TO THERACARE MANAGED SERVICES, LLC PROVIDING ABA SERVICES TO PATIENT(S). I GIVE CONSENT TO BE CONTACTED VIA ANY OR ALL CONTACT INFO THAT I HAVE PROVIDED FOR MYSELF AND/OR ON BEHALF OF MY CHILD OR CHILDREN AS PATIENTS.
I understand that TheraCare Managed Care Services, LLC, will retain Patient(s)’ medical records for the greater of six (6) years or the period required by applicable state or federal law, whichever is longer, after which they will be destroyed unless legally required otherwise.
I herein authorize payment of medical benefits to TheraCare Managed Care Services, LLC, when an assigned Patient(s)’ claim is filed.
Also, my signature authorizes TheraCare Managed Care Services, LLC to release any medical information necessary to process Patient(s)’ insurance claims or to other health practitioners for on-going treatment purposes.
Furthermore, my signature below acknowledges that TheraCare Managed Care Services, LLC has provided me with a Notice of Privacy Practice which describes how medical information about Patient(s) may be used and disclosed and how I can get access to this information, in compliance with HIPAA.
I have read and understand TheraCare Managed Care Services, LLC’s Patient Information Policy & Informed Consent Release Agreement and Notice of Privacy Practice and agree to their terms. I attest that all information given by me is known to be valid and true. A photocopy of my consent and release may be used in lieu of the original.
PRINT NAME:
DATE:
Signature of Patient or Parent/Legal Guardian: ____________________________
PRINT NAME OF PATIENT (if other than self): ________________________________