ECI of LifePath systems

Third Party Payors and Consent to bill Private Insurance

Child’s name: / Child’s date of birth: / LPS ID#:

Private Insurance and TRICARE

  • I understand that ECI of LifePath Systems is required to access any and all private, state, and federal financial supports for services.
  • I understand that I may be charged a Family Cost Share monthly fee for professional services based on my family size and income.
  • I understand that there will be no charge for service coordination, assessment, IFSP development, procedural safeguards, or parent education.
  • If my insurance carrier pays for any professional services in a calendar month I understand that this will cover my FCS for that calendar month.
  • I understand that by allowing ECI of LifePath Systems to bill my insurance, I may reach my deductible level more quickly.
  • If my insurance carrier declines to cover these professional services, I understand that I will be responsible for my FCS and that those billable services may be suspended for failure to pay.
  • I understand that insurance benefits will be assigned to LifePath Systems and if I receive a check from my insurance company for a service ECI of LifePath Systems provided, I will sign it over to LifePath Systems.
  • I understand my consent is voluntary and may be withdrawn at any time.

I hereby give permission for ECI of LifePath Systems to bill my private insurance company or TRICARE.

______

Parent signature Printed name Date

Insurance company name: / Telephone number for providers:
Primary policy holder’s name: / Policy number: / Group number: / Effective date:
If different from Consent Date
Insurance company address: / City: / State: / ZIP code:
Primary policy holder’s employer (optional):
I authorize the release of any medical or other information necessary to process this claim.
Parent’s signature: / Parent’s printed name: / Date:
No Consent to Bill
I do not give consent for the ECI program to bill my private insurance or TRICARE.
Parent’s signature:
X / Parent’s printed name: / Date:
I do not have any insurance for my child at this time. I understand that if I refuse to apply for public medical
insurance my Family Cost Share will be $10 per month regardless of my income and family size.
Parent signature: / Parents printed name: / Date:
Medicaid and Chip
I understand that when I enrolled my child in Medicaid or CHIP, I gave consent for my private insurance and/or TRICARE to be billed for services.
Medicaid MCO / Medicaid ID: / Medicaid MCO name: / MCO Member ID:
CHIP / CHIP ID: / CHIP MCO name: / MCO Member ID:

4/2012