PATIENT/CLIENT REGISTRATION FORM

Therapy Associates, Inc. 904 6th Ave Ct NE Isanti, MN 55040 Phone: (763) 444.8700 Mental Health Direct: (763) 444.7556

MEDICAL INFORMATION (for speech & occupational patients only)

If no, please indicate your referring physician or professional:

Please list other individuals who are involved in taking care of the patient/client, such as spouse, caregiver or PCA with whom you authorize Therapy Associates to discuss the patient/client's treatment.

Emergency Contact:

AUTHORIZATIONS and ACKNOWLEDGEMENTS

I have received and/or read the Notice of Privacy Practices from Therapy Associates, Inc.

I consent to the treatment necessary for the above named patient/client, this includes speech therapy, occupational therapy and/or mental health services from Therapy Associates, Inc.

I hereby authorize Therapy Associates to furnish information concerning the patient/client's illness and treatments to INSURANCE CARRIERS, PHYSICIANS, THERAPISTS, AND/OR OTHER PERSONNEL, who are involved in taking care of the patient/client.

I authorize payment of any medical benefits to Therapy Associates. I certify that the above information is correct and that I AM RESPONSIBLE FOR PAYMENT OF SERVICES RENDERED. I permit a copy of this authorization to be used in place of the original.