I authorize Black Hills Pediatric Therapy to bill my insurance company directly for the covered portion of charges and I authorize payment of benefits directly to Black Hills Pediatric Therapy. I authorize Black Hills Pediatric Therapy to release medical or other information necessary to process this claim. I understand that I am ultimately responsible for my therapy charges and I agree to pay my deductible my co-insurance or co-payment and any charges not reimbursed by my insurance carrier. I understand that some insurance companies require medical or administrative pre-authorization for treatment or have reimbursement limits on therapy treatments. I understand I am responsible for knowing and meeting the requirements of my insurance plan and/or Medicaid.