ECI of LifePath Systems

Third Party Payors and Consent to Bill Insurance

Child’s Name: / Child’s DOB: / LPS ID #
  • I understand that ECI of LifePath Systems (LPS) is required to access any all private, state federal financial supports for services.
  • I understand that I may be charged a Family Cost Share (FCS) monthly fee for professional services based on my family size and income.
  • I understand that there will be no charge for service coordination, assessment, IFSP development, procedural safeguards or parent education.
  • I understand that by allowing ECI of LPS to bill my private insurance, I may reach my deductible level more quickly.
  • I understand that I will be responsible for my FCS and that those billable services may be suspended for failure to pay.
  • I hereby assign to ECI of LPS all moneys due under my insurance company and if I receive a check from my insurance company for a service ECI of LPS provided, I will sign it over to ECI of LPS.
  • I understand that my consent if voluntary and may be withdrawn at any time.

I hereby give consent for ECI of LPS to bill my private and/or public insurance company, including all evaluations and any current or new services that may be added to my child’s IFSP throughout the year.
Parent’s Signature:Parent’s Printed Name:Date:
I authorize the release of any medical or other information necessary to process this claim.
Parent’s Signature:Parent’s Printed Name:Date:
Private Insurance and Tricare Information
No changes since last consent was obtained
Insurance Company Name:Billing Effective Date:
Primary Policy Holder’s Name:Primary Policy Holder’s DOB:
Policy Number:Group Number:
Insurance Company Address:City:State:Zip Code:
Primary Policy Holder’s Employer (optional):Telephone Number for Providers:
TMHP Medicaid and CHIP Information
TMHP Medicaid ID: TMHPMedicaid MCO Name:
CHIP ID: CHIP MCO Name:
No Consent to Bill/No Insurance
I do not give consent for ECI of LPS to bill my private/public insurance. I understand that by not giving consent, I will be billed based on my placement on the DARS sliding fee scale.
Parent’s Signature:Parent’s Printed Name:Date:
I do not have third-party coverage for my child at this time. I understand that I will be billed based on my placement on the DARS Sliding Fee Scale. If I plan to apply for Medicaid and/or CHIP, I understand that ECI of LPS may waive my FCS while Medicaid or CHIP eligibility is being determined, not to exceed 90 days.
Parent’s Signature:Parent’s Printed Name:Date:
For Office Use Only
Emailed to Billing Enrolled Not Enrolled Waiting on Enrollment

9/1/15