Consent For Treatment

Talk Time Speech and Language Services

Atlanta, GA 30319 Phone: (678) 938-4160 Fax: (678) 623-5289 Email: talktimespeechy@gmail.com
CONSENT FOR TREATMENT
I, knowing that Child's Name has a diagnosis requiring speech therapy and/or occupational therapy, voluntarily consent to such care for the aforementioned child by Talk Time Speech and Language Services, LLC as may beneficial in the professional judgement of the child's therapist. I am aware that the practice of speech therapy and/or occupational therapy is not an exact science and I acknowledge that no guarantee has been to me as to the effect of speech therapy and/or occupational therapy treatment for my child.
Child's Name

First NameLast Name
Parent/Guardian Signature

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RELEASE OF TREATMENT
I hereby authorize Talk Time Speech and Language Therapy Services, LLC to release to my Insurance Companies only such therapeutic and financial information as may be necessary to determine benefits entitled and to process payment claims for therapy services that will be provided. I hereby authorize Talk
Time Speech and Language Services, LLC to release to attending physicians and therapist therapeutic and financial information as may be necessary to coordinate my child’s therapy plan of care.
Parent/Guardian Signature

Clear
CONSENT FOR PAYMENT

I authorize Talk Time Speech and Language Services, LLC to bill my insurance company for direct reimbursement of therapy services rendered to my child. Benefit payment will be assigned directly to Talk Time Speech and Language Services, LLC c/o April Atchison.

I understand the Medicaid rate will be accepted and billed, if my child is covered by Georgia Medicaid. If I am not covered, I will be charged fees for services based on the company’s rate for an evaluation and/or treatment not covered by my insurance company.

I understand that I am responsible for payment for any service rendered to my child not covered to rates mentioned above.
Parent/Guardian Full Name

First NameLast Name
Parent/Guardian Signature

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Date

MonthDayYear
Date
Therapist/Witness

First NameLast Name
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Talk Time Speech and Language Services