In case of an emergency, who would you like for us to notify?

We recommend adding a contact that does not live in the same household.

I understand and agree to the above policies listed.

Assignment of Insurance Benefits:

I hereby authorize and request that all insurance benefits be paid to Easterseals of the Birmingham Area for services provided to the above named patient.

Consent for Medical Care:

I hereby give permission and consent to Easterseals of the Birmingham Area for therapy and other services that may be prescribed or deemed advisable for rehabilitation treatment by a physician.

Authorization to Release Non-Public Information:

I certify that I have received and read a copy of the Easterseals of the Birmingham Area Notice of Privacy Practices and patient rights. I hereby authorize Easterseals of the Birmingham Area to release any of my dependent's medical or incidental non-public personal information that may be necessary for medical evaluation, treatment, or the processing of insurance benefits. (A complete copy is provided by request or is hanging in lobby.)

Authorization to Mail, Call, Voicemail, Email, or Text:

I certify that I understand the privacy risks of mail, phone calls, email, and text messages. I hereby authorize Easterseals of the Birmingham Area representatives to mail, call, email, or text me with communication regarding my child's treatment, appointment times, and referral recommendations. I understand that I have a right to rescind this authorization at any time by notifying Easterseals of the Birmingham Area to the effect in writing.

Consent to Treatment:

I hereby consent to evaluation, testing, and treatment as directed by my Easterseals of the Birmingham Area's therapist or his/her designee.

Confidentiality:

I understand that Easterseals of the Birmingham Area will not disclose or release information created or received about the above patient except for the purpose of:

1. Appropriate medical treatment and/or development/assessment.
2. Release to insurance companies for the purpose of payment.
3. Other health care operations such as review of staff monitoring and/or evaluation and for purposes of quality assurance monitoring. For certain instances, I understand that I must sign an authorization permitting the disclosure or release of information.

I hereby give Easterseals of the Birmingham Area the absolute and irrevocable right and permission, with respect to photographs, story of me or intellectual property developed while in the Easterseals of the Birmingham Area's program:

To use, re-use, publish, and re-publish the same in whole or in part, individually or in conjunction with other photogrpahs, in any medium (included but not limited to newsletters, nominations, community awareness, social media, and as of yet unheard-of media) and for any purposes whatsoever, including (but not by way of limitation) illustration, promotion, ad adverstising and trade, for a period of five years.

I hereby release and discharge Easterseals of the Birmingham Area, from any and all claims and demands arising out of or in connection with the use of photographs, story, or intellectual property developed while in the Easterseals of the Birmingham Area's program, including any claims from libel.