Name of Child:
Date / Service Provided (Circle Only One) / I am the parent or legal guardian of the above named child and I certify that the child received services as documented on this form. I authorize the release of any medical or other information necessary to process claims associated with services delivered as documented on this form. I authorize payment of medical benefits to Caring Family Community Services. I request payment of government benefits either to myself or to the party who accepts assignment. I also agree that my credit card on file may be charged for any applicable copayments, coinsurances, deductibles or other charges not covered by my insurance or I agree that I will pay those applicable charges by mailing a check to Caring Family Community Services within 15 days of the service delivery date.
Start Time / ABA Assessment
ABA Supervision
ABA Reassessment
ABA Support / IIH- BCBA Services
IIH- Support Bachelors
IIH- Support HS
Other ______
End Time
Date of Next Appt
PARENT/GUARDIAN SIGNATURE
Date / Service Provided (Circle Only One) / I am the parent or legal guardian of the above named child and I certify that the child received services as documented on this form. I authorize the release of any medical or other information necessary to process claims associated with services delivered as documented on this form. I authorize payment of medical benefits to Caring Family Community Services. I request payment of government benefits either to myself or to the party who accepts assignment. I also agree that my credit card on file may be charged for any applicable copayments, coinsurances, deductibles or other charges not covered by my insurance or I agree that I will pay those applicable charges by mailing a check to Caring Family Community Services within 15 days of the service delivery date.
Start Time / ABA Assessment
ABA Supervision
ABA Reassessment
ABA Support / IIH- BCBA Services
IIH- Support Bachelors
IIH- Support HS
Other ______
End Time
Date of Next Appt
PARENT/GUARDIAN SIGNATURE
Date / Service Provided (Circle Only One) / I am the parent or legal guardian of the above named child and I certify that the child received services as documented on this form. I authorize the release of any medical or other information necessary to process claims associated with services delivered as documented on this form. I authorize payment of medical benefits to Caring Family Community Services. I request payment of government benefits either to myself or to the party who accepts assignment. I also agree that my credit card on file may be charged for any applicable copayments, coinsurances, deductibles or other charges not covered by my insurance or I agree that I will pay those applicable charges by mailing a check to Caring Family Community Services within 15 days of the service delivery date.
Start Time / ABA Assessment
ABA Supervision
ABA Reassessment
ABA Support / IIH- BCBA Services
IIH- Support Bachelors
IIH- Support HS
Other ______
End Time
Date of Next Appt
PARENT/GUARDIAN SIGNATURE
Employee Signature (required) Date