Attestation to Eligibility and Benefits-PlayRx

Attestation to Eligibility and Benefits

Form for acknowledgement of receipt of estimated eligibility and benefits.

Beneficiary's First Name

Beneficiary's Last Name

Guarantor (Parent's Full Name)

I understand that it is my responsibility to alert PlayRx immediately to any changes in the insurance outlined in this complimentary Eligibility and Benefits Summary. If I fail to alert PlayRx of a change that ultimately invalidates the Insurance Coverage I have provided, I understand that I will be charged PlayRx's private pay rates for all services already provided and unable to be applied to PlayRx Accepted Insurances. Private Pay Rates are as follows: $200/hour of Evaluation and/or $100/hour of Speech, Occupational, Physical Therapy Treatment.

Initial below to signify your understanding and agreement with the previous paragraph.

Terms and conditions: I have received the estimated expense associated with my insurance plan's eligibility and benefits associated with PlayRx services. I understand this is only an estimate and that my actual financial obligation for therapy services will be determined by the Explanation of Benefits generated following claim adjudication.

I agree to the terms & conditions outlined above.

Date

Your Signature