You would like or your child   First Name   Last Name   is being recommended for a screening and/or speech/language evaluation (if needed). The Speech & Language Corner, PLLC, will provide free speech/language services to children with Medicaid.

First Name   Last Name   I hereby give my permission for The Speech & Language Corner, PLLC to conduct a speech language screening and/or evaluation, and if eligible for needed treatment (i.e., speech/language therapy, consultation). This consent provides the Speech & Language Corner, PLLC with the authority to bill my Medicaid insurance for all therapy services provided. The signed consent also gives the Speech & Language Corner, PLLC the permission to exchange and share information pertinent to the student to/from the therapist and the child’s primary care physician group. If the child qualifies for therapy then services will occur during the school day.

Signature of Patient/Parent Legal Guardian or Other Legally Responsible Person