Consent to Evaluate and Treatment Form Sage Speech & Language, LLC

Consent to Evaluate and Treatment Form Sage Speech & Language, LLC
Date

MonthDayYear
Date
Legal Name of Child

First NameLast Name
Date of Birth of Patient (child)

MonthDayYear
Date
Child's Pediatrician and Clinic Name
Consent to Evaluate, Treat, and Coordinate Care

I, the undersigned parent or legal guardian, give my informed consent for Sage Speech & Language, LLC to complete a speech-language evaluation of my child listed above.

If the evaluation indicates that speech-language therapy is medically necessary, I further give my consent for speech-language treatment services to be provided.

I understand and acknowledge that speech-language services provided by Sage Speech & Language, LLC are medical services and require coordination of care with my child’s medical provider. As part of this coordination, I authorize Sage Speech & Language, LLC to share copies of my child’s speech-language evaluation results and Plan of Care with my child’s pediatrician or primary care provider, including by secure fax or other HIPAA-compliant means.

I understand that authorization to share evaluation results and the Plan of Care with my child’s pediatrician is required in order for speech-language treatment services to be provided, and that services cannot be initiated or continued without this authorization.

I understand that I may withdraw my consent for evaluation or treatment at any time by providing written notice.
Name of Parent/Guardian

First NameLast Name
Electronic Signature
By typing my name above, I understand that I am providing an electronic signature, which is legally binding and has the same validity and effect as a handwritten signature.
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