AOT & CST Intake Form

I am authorizing Advantage Therapy & Rehabilitation [AT&R] and/or Coastal Speech Therapy [CST] as the preferred provider to provide occupational, physical, and/or speech therapy services to the patient listed above. At any time, I have the right to refuse treatment by notifying the provider of such decision. Our provider offices may also terminate services at anytime by giving notification and reason for such decision.\I am requesting that payment of private insurance, medicare/medicaid be made to AT&R and/or CST for therapy services to the patient listed above. I authorize any necessary protected health information of mine be released to insurance companies in determining payment and authorization for services. I agree to pay in full for all services provided by AT&R and/or CST for any remaining balance due after insurance has been billed.*I understand that it is my responsibility to notify AT&R and/or CST of any changes with insurance and/or primary care physician. I understand that I am held responsible for any amount not covered by the insurance related to these changes.

I understand that AT&R and/or CST will only disclose my protected health information for treatment purposes or obtaining payment for therapy services. I acknowledge this use and disclosure of my personal health information by signing below. I hereby authorize the mutual exchange of information regarding the above named person between AT&R and/or CST between the child's primary doctor and any other individuals or agencies listed below.This patient's information may be used by the person(s) and/or agencies I authorize for medical treatment, consultation, billing, or other purposes. This authorization shall be in force and effect while patient is being treated by AT&R and/or CST. I understand that I have the right to revoke this authorization in writing at any time. 

By Signing below, you agree that Advantage Therapy & Rehabilitation is the preferred provider for OT & PT services and Coastal Speech Therapy is the preferred provider for speech therapy services for the pediatric patient. By signing below you agree that the previous provider has been made aware of the change.