By signing this form, you give Louisville Therapy Group, PLLC, permission to file a claim with your insurance company on or after the indicated date via a third party billing company (Grey Ledge Medical Management). This is permission for current and future services as outlined in this agreement, and does not provide authorization for unrelated services to your account.

I understand that the provided insurance company will be billed for services rendered (after each session).

I authorize Louisville Therapy Group, PLLC to bill the insurance company indicated in this authorization form according to the terms outlined above. This payment authorization is for therapy services, for the amount invoiced by the practice, and is valid for ongoing monthly and weekly services. I certify that I am an authorized member of this account and that I will not dispute the payment with my insurance company; so long as the transaction corresponds to the terms indicated in this form.