I authorize Small Talk Pediatric Therapy to render appropriate therapy services to the below-named patient. I understand that care will be provided by an appropriately trained health care professional. I hereby authorize Small Talk Pediatric Therapy to bill Medicaid and/or my private insurance for covered services; and to exchange information necessary to secure payment for these services. Such necessary information may include my child’s diagnosis, service dates, types of services and other information related to the Small Talk’s services necessary to process claims. Co-payment(s), deductibles, and/or percentages that are not covered by insurance are due at the time of service. According to Idaho Law, co-payments and deductibles cannot be waived. If these payments, or the like, are not paid at the time services are provided, this is no way inhibits Small Talk Pediatric Therapy the right to demand payment for the same by the Signer under the terms of this agreement. I will notify Small Talk Pediatric Therapy of any changes to my child’s health insurance coverage, as well as any denial information. I understand that I am responsible for any balance that Medicaid and/or my private insurance does not authorize for payment.
I consent and agree that Small Talk Pediatric Therapy and its staff may contact me, leave voice messages, send me text messages and/or send me emails to the phone number(s) and email address(es) I have provided them. I understand that these messages can include protected health information, such as patient name, appointment information, billing information, information that identifies the practice, and any pertinent clinical information. I understand that text messages and emails are not secure forms of communication, and that by consenting to these communication types, I am waiving my rights to secure electronic communications. Small Talk Pediatric Therapy may send me informative emails that contain newsletters, information about treatment alternatives or other health related benefits.
I hereby authorize and request that copies of my prior medical records related to speech-language pathology, occupational therapy and or physical therapy evaluation or treatment services be delivered to Small Talk Pediatric Therapy to establish or continue my health care treatment plan. This includes the complete assessment, most recent plan of treatment, progress summary, treatment notes and any other appropriately related documents or information. I understand that for the purpose of continuing and coordinating my plan of treatment Small Talk Pediatric Therapy may be asked to release copies of my medical records, or such portions thereof as may be relevant to any and all services provided at Small Talk to other health care providers, facilities (related school or case managers, physicians etc.) and appropriately related professionals involved in my care.
I have read and fully understand the content of this consent and authorization release and hereby agree to and authorize the foregoing provisions. As used in this document, the terms “I”, “me” and “my” refer to and include, in addition to the undersigned, the patient named below and other for whom the undersigned is responsible or for whom the undersigned has assumed responsibility in engaging
Small Talk Pediatric Therapy to provide services to the patient. This authorization will continue for one year from the date signed or upon my written request to deny future releases.