I hereby give consent to Pediatric Occupational Therapy Services, LLC to provide treatment and procedures as needed for my child.
I authorize the release of all medical and/or further information necessary to process all claims pertinent to my child's medical care for services rendered by Pediatric Occupational Therapy Services, LLC.
I authorize payment of medical benefits to Pediatric Occupational Therapy Services, LLC for services rendered and understand that my insurance plan does not guarantee payment of my bill.
I have read each paragraph and agree to abide by the office policies and procedures set forth by Pediatric Occupational Therapy Services, LLC.
My signature below acknowledges that I understand that I am financially responsible and accept liability for all charges incurred at Pediatric Occupational Therapy Services, LLC.
By signing this form, I acknowledge that I have received a copy of and am in agreement with the Pediatric Occupational Therapy Services, LLC Notice of Privacy Practices, Financial Policy, Cancellation Policy and Consent for Release of Information