Authorization Signature Form – moorepediatricnc.com

Patient Registration Form

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.

Authorization Signature Form

Parent/Guardian First Name *

Parent/Guardian Last Name *

Relationship to Patient *

Email *

Child's Name *

Date Of Birth *

AUTHORIZATION PAGE

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 *

I have read Moore Pediatric Therapy Services, LLC (MPTS) financial policy statement and I UNDERSTAND MY RESPONSIBILITIES FOR THE PAYMENT OF MY ACCOUNT. *

CONSENT FOR CARE AND TREATMENT *

By my signature below, I do hereby agree and give my consent for MPTS to furnish necessary evaluations and treatment. *

BENEFIT ASSIGNMENT / RELEASE OF INFORMATION *

I, hereby assign all medical benefits to include major medical benefits to which I am entitled, including Medicaid, private insurance and third-party payers to MPTS as it may be necessary for billing and collection purposes. A photocopy of this assignment is to be considered as valid as the original. *

INFORMATION PRIVACY STATEMENT (HIPAA) *

MPTS will use and disclose you(r) child’s personal health information to treat them, to receive payment for the care we provide, and for other health care operations. Health care operations generally include those activities we perform to improve the quality of care. By signing below, I acknowledge receipt and review of MPTS’s Notice of Privacy Practices. *

POLICIES AND PROCEDURES *

I have received and familiarized myself with MPTS Policies and Procedures and agree to the statements regarding our treatment session times, cancellation and no show policy, sick and discharge policy, and patient rights and responsibilities. *

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 Information *

I hereby authorize Moore Pediatric Therapy Services, LLC to release and receive information in my patient record to: *

This request shall be valid for the duration of treatment unless previously revoked or otherwise indicated (specify the number of days or months):

Reason for Release

Other

Consent *

I understand that by signing this form, that I hereby agree and authorize the release of patient information to the above named person or organization. I have the right to revoke this authorization, in writing, at any time by sending such a written notification to Moore Pediatric Therapy Services, LLC office address. However, I understand that my revocation will not be effective to the extent that action based on this consent has been taken. *

Printed Name and Relationship*

Signature*

Date*

Patient Registration Form

At Moore Pediatric Therapy we focus on the potential of each child and encourage and promote parental partnerships with each therapist.

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