FINANCIAL RESPONSIBILTY AGREEMENT

{Company Name} aims to help as many families as possible, and we seek out various funding opportunities, including insurance, state, county, and self-funding.

Insurance: {Company Name} will ensure that all preauthorization, assessment and progress reports are completed and submitted before the due dates to continue ongoing therapy. However, if any claim comes back as uninsurable, you will be billed for the full amount of services after 60 days. As such, it will be your responsibility to contact your insurance company for reimbursement. You are responsible for any charges, or portions of charges that your insurance company does not cover. A Piece of the Puzzle Behavioral Interventions LLC will release all necessary paperwork to the parent or caregiver as requested.

{Company Name} is in a network with the following insurance companies:

Anthem, Aetna, Cigna, and Husky

If your insurance is funded through the state or county, {Company Name} will ensure all assessment and progress reports are completed and submitted before the due date, to continue ongoing therapy. {Company Name} promises to not exceed the total funded amount without the expressed consent of the parent/caregiver. However, if you request additional sessions above and beyond the funded amount, you will be responsible for payment of these additional services. Before beginning any additional sessions, the case manager will be notified, and a client contract will be signed with the total amount of sessions above the funded amount.

INVOICES:
{Company Name} will invoice families with balances monthly. You will receive an itemized invoice, with a breakdown of the date of service, time of service, and service type. You will receive an electronic invoice by the tenth day of each month. Paper copies are available upon request; to receive a paper copy, please send an email to Jessicag@puzzlellc.com.

The parents/guardians of the child receiving services remain completely responsible for the full payment of all services, including late payment fees. We accept payment via Ivy Pay, cash, or check. It is recommended that clients use online banking where possible.

Fees:

There is a $40.00 fee for all checks returned by the bank.

Payment Agreement:

Please initial which type of payment terms you are requesting.

I have insurance coverage and authorize direct payment from my insurance carrier to {Company Name}.
Please initial
I have Husky Insurance; all claims will be paid by the Husky- funding source.
Please initial
I have primary insurance coverage through and authorize direct payment from my insurance carrier to {Company Name}. Please initial
I also have secondary insurance coverage through and authorize direct payment from my secondary insurance carrier to {Company Name}. Please initial

ABA Therapy Service Agreement

During the term of this agreement, A Piece of the Puzzle Behavioral Interventions LLC will provide ABA Therapy services, and the parents/guardians will compensate A Piece of the Puzzle Behavioral Interventions LLC a payment for the services as described below in the terms and conditions specified. I understand all the fees and conditions as stated above.

IF IT BECOMES NECESSARY FOR THIRD PARTY COLLECTION, I AGREE TO PAY FOR ALL COSTS AND EXPENSES INCLUDING REASONABLE ATTORNEY FEES

Services

During the terms of this agreement {Company Name} shall provide the following services:

Behavioral treatment services, which may include, but are not limited to: direct one-onone instruction, a continuation of assessments, and modification of programs (data collection and review as required for evidence-based ABA practices), completion of Functional Behavior Analysis for problem behaviors, and update of Behavior Intervention Plan (BIP), and parent training.

I agree to the terms of the above agreement:

PARENT/GUARDIAN NAME:

DATE:

PARENT/GUARDIAN SIGNATURE:

Please sign in the box below using your mouse, touch screen, or touchpad

Clear

I accept that this is the legal representation of my signature.