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We consider ourselves part of your child's team and welcome collaboration with all family members and professionals who are involved in your child’s care. I grant permission to POTS to be in contact with the following teachers, professionals or family members who I deem necessary to help my child achieve his/her goals.
Release FormsI hereby authorize Pediatric Occupational Therapy Services to:Send me and anyone listed above appointment reminders via e-mail, text messaging or phone that may contain patient or clinical information such as, but not limited to, patient first name and clinic location.Initials: initials Contact my child's pediatrician and send him/her initial reports, plans of care and progress notes, or contact him/her by phone. Initials: Be in contact with my child's teacher by phone and email.Initials: I give permission for occupational therapy students and visiting therapists to observe my child’s therapy.Initials: I give permission for photographs/videotapes to be taken of my child for:In-house educational purposes at POTS and physicians/professional offices. Initials: The POTS website and social media. We will not use your child's name without your permission. Initials:
I acknowledge that my child's therapy is performed in a shared, open treatment area with other clients and families present. I understand that conversations that occur in such an area may be overheard by others. If you would prefer a confidential conversation, please request a private area for discussion with your therapist to ensure that details are not overheard by others.Initials: Type a label
POTS understands that you may not always be available to bring your child to therapy. Please list the names and cell phone numbers of people who may bring your child to therapy and let us know if you would like us to discuss your child's progress with them
Your child's health and safety are of paramount importance to us.From time to time therapists use examination gloves and various foods in the course of therapy to assess and treat oral motor and feeding skills. We are aware that some children are allergic to the materials used in examination gloves, may be on specialized diets, or may be allergic to various foods. Please read below carefully and indicate any allergies that your child has that you are aware of below Please list other known allergies as well. The information will be noted in a prominent place in your child's chart. Please keep us informed of any allergic reactions that emerge over the course of his/her therapy program.blanksblank
I have provided information to the best of my knowledge at the request of Pediatric Occupational Therapy Services, LLC. I will be responsible for notifying POTS of any changes in the status of the above information.Initials: Type a label
I hereby authorize Pediatric Occupational Therapy Services to send me electronic invoices and receipts via e-mail containing patient or clinical information such as, but not limited to, name and address, date of birth, diagnosis, therapist and clinic location, date of appointment, rate and total amount due. Initials:
Pediatric Occupational Therapy Services requires a credit card on file while your child is under our care. I authorize Pediatric Occupational Therapy Services to capture my credit card information and securely store my credit card electronically. I authorize Pediatric Occupational Therapy Services to charge the credit card on file for any balance owed. I certify that I am an authorized user of this credit card. I understand that if I have a new credit card I will promptly update my credit card information for your records. Please call the office at 201-837-9993 to provide your credit card information over the phone.
I here by certify that I have read and understood all of the above.
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