All fields marked with * are required.
Please fill out this form to the best of your ability. If you have any questions, please call us at 910-673-5437.
This form gives us permission to bill your insurance, permission to evaluate
and treat and states that you have read the
financial policies and procedures and received our HIPAA statement.
FINANCIAL POLICY STATEMENT *
CONSENT FOR CARE AND TREATMENT *
BENEFIT ASSIGNMENT / RELEASE OF INFORMATION
INFORMATION PRIVACY STATEMENT (HIPAA) *
POLICIES AND PROCEDURES *
AUTHORIZATION OF RELEASE/RECEIPT OF PATIENT INFORMATION
Please list anyone with whom we can receive and release information about
your child. For example, your pediatrician,
CDSA (Children’s Developmental Services Agency or early intervention),
public school, other therapists and/or specialist
physicians. If someone is not listed on this form we cannot share or receive
information with them
Authorization of Release/Receipt of Patient