INFORMED CONSENT TO BILL HEALTH INSURANCE PLANS

FOR AUTISM SPECTRUM DISORDERSERVICES

Child’s Name / Record #

For young children,Connecticut Public Act 09-115 “An Act Concerning Health Insurance Coverage for Autism Spectrum Disorders”, requires heath insurance plans to reimburse for: 1) as many occupational therapy, physical therapy, and speech/language therapy visits as required by an approved treatment plan; and 2) behavioral therapy services up to $50,000 per year.

Connecticut law also requires the Birth to Three System to charge fees to all parents whose adjusted gross family income is $45,000 or more, using a sliding scale that considers family income and family size. These fees are doubled in cases where permission to bill insurance is not granted.

If you gave permission for your health insurance to be billed (Form 1-3a), your Birth to Three program will bill until the insurance payments reach the $6,400 annual limit. By signing this form you give permission for your health insurance to also be billed under the Health Insurance Coverage for Autism Spectrum Disorders Act.

In order for you to make a decision to allow the Birth to Three System to continue to bill your health insurance plan for autism services, you should consider the following:

  • Your child will require an annual diagnosis of autism spectrum disorder (which your program can provide).
  • The decision to allow or not allow billing for autism services is completely up to you as the named insured.
  • Your decision may be changed at any time and for any reason.
  • Your child and family will continue to receive the services and supports specified on your

Individualized Family Service Plan (IFSP) regardless of your decision about insurance billing.

  • Your health insurance plan may or may not agree to cover autism services. Their decision will not affect the amount of your fees nor the services your child receives.
  • If your health plan decides to provide coverage, the plan may apply such payments against the maximum annual or lifetime limits of the policy.
  • If you decline to allow billing for autism services your fees (if any) will be charged at a higher rate.

I hereby grant permission to the Birth to Three System Lead Agency and its agents as described in Form 1-3 to receive reimbursement for claims submitted to my insurance carrier on behalf of my child. I understand that this may affect the maximum lifetime or annual limits specified in my policy.

I do not grant permission for my insurance to be billed by the Birth to Three System and its agents. I understand that if I do not give permission for my insurance to be billed my family cost participation will be based on the higher fee schedule.

This permission remains in effect during the time in which my child is enrolled in the Connecticut Birth to Three System or until I revise this form to indicate otherwise. If neither box is checked or if there is no signature on this form, it means that higher fees will be charged.

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Parent SignatureDate

Connecticut Birth to Three Form 1-3b (1/12/10)