Informed Consent for TEFRA for Advanced Counseling-PlayRx

Informed Consent for TEFRA for Advanced Counseling

Child’s First and Last Name

Place a check next to the following items to signify your understanding and agreement to each statement.

In order to provide patients with comprehensive counseling and to ensure the TEFRA process is adhered to, I will provide the PlayRx Resource Specialist with the following information in a timely manner:

Date of completion of the Physician Form

Completion of TEFRA application within 30 days of initiation of TEFRA counseling with PlayRx

Date of Application Submission. IF MAILING CERTIFIED: provide receipt from DHS office or receipt from post office with tracking number. IF COMPLETED ONLINE: provide a screenshot of confirmed submission.

PlayRx cannot guarantee reimbursement for services in the amount of copays or other out of pocket costs that were provided prior to TEFRA approval.

Your First and Last Name

Date

Your Signature