Private Pay: TEFRA Attestation
Child First Name
Child Last Name
Please check the following boxes to signify your understanding and agreement of each point:
I understand that outside of a qualifying medical diagnosis, to apply for TEFRA my child must qualify for therapy services according to Arkansas Medicaid Beneficiary Standards by showing at least a moderate developmental delay on standardized testing
Should my child qualify for therapy and be eligible to apply for TEFRA, I will provide proof of TEFRA application submitted to PlayRx WITHIN 30 DAYS OF RECEIPT OF QUALIFYING EVALUATION FROM PLAYRX
Proof of TEFRA submission MUST BE documentation of TEFRA Application Date from either Arkansas Children's Hospital or a local DHS office
If I fail to provide proof of application for TEFRA coverage to PlayRx within 30 days of receipt of my qualifying evaluation report, I authorize PlayRx to collect their private pay rate for the clinical services my child received
Should my child NOT qualify for therapy by Arkansas Medicaid standards, I understand that I will not be charged for the Evaluation Provided. If I desire further services, I agree to be charged PlayRx Private Pay Rates
Card Information:
Name on Card
Card Number
Expiration Date
Security Code
Billing Address
Signee's First and Last Name
Your Signature
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