Parent Consent for Screening/Evaluation

I hereby represent and acknowledge that I am the parent and/or legal guardian of the above-named child, who is my lawful son/daughter.

I give consent to TALKING STEPS BY STEPS to do the Screening, Evaluating Speech, Language & Voice.

This consent is valid while the child listed above is enrolled in TALKING STEPS BY STEPS concerning the care and treatment being provided.

Insurance Information

I authorize Talking Steps by Steps to release all information needed for related Medicaid, or any other insurance holder, to the social security administration or its intermediaries or carriers. I permit a copy of my authorization to be used in place of the original. I hereby authorize payment if any, to be paid directly to TALKING STEPS BY STEPS for medical benefits. If for any reason full payment is not received, I accept full responsibility to pay whatever charges remain. If do not pay such charges and it becomes necessary for you to file suit against me to collect such charges, I agree to pay for a reasonably attorney fee and the cost of the collection.

Prenatal and Birth History

Prenatal and Birth History

Developmental History

How old was your child when

Feeding

Sensory Motor Skills

(Check all that applies)

Educational History

Medical History

Has the child had any of the following illnesses?

Patient Hipaa Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office. You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you Consent to our use and disclosure of protected health information about you for treatment, payment, and health operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosure we have already made in reliance on your prior consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:

• Protected health information may be disclosed or used for treatment, payment, or health care operations
• The practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice
• The practice reserves the right to change the Notice of Privacy Practice
• The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions
• The patient may revoke this Consent in writing at any time and all future disclosures will then cease
• The practice may condition receipt of treatment upon the execution of this Consent

Please give any additional comments in reference to the release of your medical condition(s) or appointments: