By signing this form, you are acknowledging...
- It is the family's responsibility to verify insurance coverage, including but not limited to: prior authorization and referral requirments and obtaining said authorization or referral when necessary; deductible and copayment amounts; and any coverage limitations.
- Providing the insurance information does not guarantee coverage of services provided.
- If this information was provided after the effective date of the new plan, Boston Ability Center is not responsible for any charges not covered by the insurance company for any reason.
- All inforamtion provided on this form is accurate.