CONSENT FOR CARE & TREATMENT
I, the undersigned, do hereby agree and give my consent for Julie Abrams, OTR,LLC and Associates: Amanda Betzen, OTR, LLC, to provide occupational therapy evaluation and treatment to my child (name listed above) that is considered necessary and proper in treating his/her condition.
AUTHORIZATION BENEFIT ASSIGNMENT-FINANCIAL RESPONSIBILITY-RELEASE OF INFORMATION
I certify that the information given in applying for payment of charges under Title XVII or XIX of the Social Security Act or other governmental medical assistance programs is correct and I authorize the release of all information necessary to act on this request. I request that payment of authorized benefits under the Social Security Act or other program be made to Julie Abrams, OTR, LLC and Associates on behalf of the patient.
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
I have had full opportunity to read the Julie Abrams, OTR, LLC and Associates Notice of Privacy Practices. I understand that by signing this consent, I am giving my consent to Julie Abrams, OTR, LLC and Associates to use and disclose my protected health information to carry out treatment, payment activities and health care operations. I understand the terms of this notice may change with time and Julie Abrams, OTR, LLC and Associates will always post the current notice at the farm, on the website and have copies available for distribution.
SIGNATURE FOR CONSENT
By my signature below I acknowledge that I have read, understand and agree to the terms and conditions contained in the Consent for Care and Treatment, the Authorization to release all information necessary to secure payment and the Consent For Use and Disclosure of Health Information.
SIGNATURE FOR UNDERSTANDING FAQS
By my signature below I acknowledge that I have read, understand and agree to the terms and conditions contained in the Frequently Asked Questions handout included.