New Patient Packet

E-mail:*

Child Information

Child's Last Name:*
Child's First Name:*
Child's Middle Name:*
Age:*
Date of Birth:*
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Social Security Number:
Home Phone:*
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Address:*

Parent or Legal Guardian Information

Full Name:*
Relationship To Child:*
Full Address:*
Home Phone (if different from Child):
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Cell Phone:
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Occupation:*
Name of Employer:*
Business Phone:*
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Condition Information

Child's Diagnosis:*
Date of Diagnosis:*
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 / 
Other Condition:
Diagnosis Date of Other Condition:
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 / 
Primary Pediatrician/Physician:*
Specialty:*
Pediatrician/Physician Address:*
Pediatrician/Physician Phone:*
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Pediatrician/Physician Fax:
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Source of Funding:*
Medical Insurance Provider:*
Policy #:*
Group #:*
Plan Name:*
Other Physicians/Specialists who provide care for this child:

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Confidential Release

I do hereby authorize: Communicate to Connect Therapy, LLC., including all employees, to RELEASE TO and OBTAIN FROM information from the record of
(enter child/client's name here):
The information that may be released includes (select all the apply):*

 I understand that I need not consent to the release of this information. However, I choose to do so willingly and voluntarily for the purpose(s) specified above.

I understand and agree that a this electronic signature of this executed authorization is as valid as the original.

I understand that I may revoke this authorization at any time (except to the extent that action has been taken in reliance thereon), by written, dated, communication to the Owner of Communicate to Connect Therapy, LLC.

By typing your full name/initials and date, you are signing this consent form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this consent form. You also represent that you are authorized to provide consent for the client whom this document is in regards to.

Your Signature:*
Signature Date:*

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Authorizations and Acknowledgements

- You May Refuse to Sign This Acknowledgement -

Consent for Treatment
I hereby authorize Communicate to Connect Therapy, LLC to provide my child with Speech Therapy services. I consent to care and treatment falling under the practice guideline of the American Speech-Language-Hearing Association (ASHA), and the State of Georgia.
Parent Initials (1):
Video/Photo Release
I hereby authorize Communicate to Connect Therapy, LLC to photograph, audio tape, and/or video tape my child.

I hereby authorize Communicate to Connect Therapy, LLC to use photographs, audio tapes, and/or video tapes of my child for educational, advertising purposes, reports for insurance companies, referring physicians and other families for continued care.
Parent Initials (2):
Cancellation Policy
I acknowledge that I have received a written copy of the Communicate to Connect Therapy, LLC ‘Parent Letter and Cancellation Policy’. This policy states that I will give appropriate notice for cancellation of my child’s appointments or it will be considered a missed appointment. I also acknowledge that I have been allowed to ask questions concerning this notice and my rights under this notice. I understand that by signing this form I am solely responsible for charges due to a missed appointment and will pay the charges or therapy sessions may be terminated.
Parent Initialsl (3)::
Payment Policy
I acknowledge that I have received a written copy of the ‘Payment Policy’ for Communicate to Connect Therapy, LLC. This policy states that I am required to pay for services prior to or at the time that services are received. If I elect to pay by credit card, I agree to provide an account number to be kept on file. I acknowledge that I have been allowed to ask questions concerning this notice and my rights under this notice. I understand that by signing this form I am solely responsible for all charges related to services and for any late or insufficient fund fees.
Parent Initials (4)::
Privacy Practices
I acknowledge that I have received a written copy of the ‘ HIPPA Notice of Privacy Practices’ for Communicate to Connect Therapy, LLC concerning the release of my child’s medical information and insurance information.
Parent Initials (5)::

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Your Electronic Signature:*
Today's Date:*
Time:*
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Word Verification:

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