ADOS-2 Autism Assessment Authorization

ADOS-2, a gold-standard observational assessment used to evaluate individuals for autism spectrum disorder (ASD). This assessment is suitable for children, adolescents, and adults. Modules are selected based on age and language ability

This service includes:

• Intake Interview (45-60 mins)
• ADOS-2 Testing Session (45-90 mins)
• Scoring, Interpretation & Written Report
• Feedback Session (30-60 mins)

As a participant in ADOS-2 assessment, I freely and voluntarily agree to accept this treatment contract as follows:

• I understand that some or all the services may not be considered eligible for benefits (e.g., some services may be determined to be not medically necessary, non-covered) by my health insurance plan.
• Under my health plan, I am financially responsible for co-payments, co-insurance or deductibles for covered services. I am also financially responsible for all non-covered services, including care determined to be elective or maintenance.
• Some of the services or products listed above are not covered according to my health plan. My acknowledgement below indicates that I have been advised of this information and that I agree to pay for the listed services or products.

FEE SCHEDULE:

Some services are covered by insurance and the patient is responsible for copay and/or 100% UNTIL DEDUCTIBLE IS MET per session.

Intake Interview:
$150 cash price
Copay or Deductible if applicable /session with insurance

ADOS-2 Testing Session, Interpretation and Scoring:
$600 cash price, Certus will not file this claim with my insurance

Feedback Session:
$150 cash price
Copays or Deductible if applicable /session with insurance

My signature below indicates that I agree to follow the obligations and responsibilities outlined in this agreement and authorize Certus provider to conduct the ADOS-2 assessment for myself/my child.