I give permission to receive an occupational therapy evaluation. I understand that enrollment in a treatment program may be recommended.
It is my responsibility to notify Highest Potential Therapy, Inc. prior to any insurance changes even if I have Medicaid coverage, as adding or changing a primary insurance may require prior authorization for services. If prior authorization is not obtained secondary to not notifying Highest Potential Therapy, Inc. about the change in insurance, I will be responsible for services not covered by the insurance (applies to clients covered by Medicaid).
It is my responsibility to notify Highest Potential Therapy, Inc. regarding prior therapy services received as well as future decisions to seek therapy services from other service providers. I understand that seeing multiple providers may affect my insurance coverage, and I will be held responsible for any balance due should billing complications arise (applies to clients covered by Medicaid).
I understand that Highest Potential Therapy, Inc. will honor new Medicaid coverage moving forward from the time a family provides a copy of the insurance card and after prior authorization has been approved by Medicaid. Please note that Highest Potential Therapy, Inc. is unable to bill Medicaid retroactively, even if Medicaid authorizes retroactive billing.
If I am responsible for a full payment or a co-payment amount, I authorize my credit card to be charged the full amount due. Highest Potential Therapy, Inc. will make every effort to give warning that the charge will be made.
I authorize the release of any medical or other information necessary to my insurance company to process claims.