Authorization to Bill for Services

I authorize StarBright Applied Behavior Analyst, PLLC to bill my insurance company for medical services rendered and to receive payment directly from my insurance company and I consent to the release of medical information necessary to process any insurance claims. A copy of this authorization may be used in place of the original. I also consent to the release of medical information to other physicians who participate in my child’s treatment. I agree to update my insurance information on file with StarBright Applied Behavior Analyst, PLLC. In the event that I fail to provide updated insurance information, then I will be responsible for payment to StarBright ABA for the cost of services at StarBright ABA’s service rates.