Financial Responsibility Agreement

I understand that Raven Behavior Analysis will bill my insurance company for services rendered, including Applied Behavior Analysis (ABA) therapy and related behavioral health services.

I understand that I am financially responsible for any copayment, co-insurance, deductible, out-of-pocket expense, or outstanding balance that is not covered by my insurance plan, including any portion that my insurance determines to be my responsibility.

I understand that insurance coverage is not a guarantee of payment, and that I remain responsible for any balances left unpaid by my insurance company, including denials or non-covered services.

I authorize Raven Behavior Analysis to release any information necessary to process insurance claims, and I authorize payment of insurance benefits directly to Raven Behavior Analysis for services rendered.

I understand that I will be billed for any outstanding balances and that payment is due upon receipt of my statement. I agree to notify Raven Behavior Analysis of any changes to my insurance coverage.