Disclosure of Protected Health Information and Consent to Treat

I hereby authorize KidSpeak Speech and Language Services to directly receive payment of pertinent insurance benefits, to release information including protected health information to insurance companies, my child’s physician, and other related third parties as needed in relation to the filing for or collection of payment for provided services, to obtain records from other sources as needed in relation to patient diagnosis and treatment, and to convey information through various means as needed in accordance with the Notice of Privacy Practices, a copy of which was made available to me. By signing this form, you acknowledge receipt of the Notice of Privacy Practices of KidSpeak Speech and Language Services. Our Notice of Privacy Practices provides information about how we may use and disclose your protected health information. We encourage you to review it carefully. Our Notice of Privacy Practices is subject to change. If we change our Notice, you may obtain a copy by asking our Privacy Officer who will provide one to you. I acknowledge receipt of the Notice of Privacy Practices of KidSpeak Speech and Language Services.

I hereby give consent to KidSpeak Speech and Language Services to provide services as needed for my child.