Permission and Consent
I give permission for a licensed therapist from SPEECH READS THERAPY to conduct a speech-language screening with my child at my child's learning center in a focused environment outside of their usual classroom. A daycare staff member may or may not be present during these sessions. Following the screening, I understand that I will receive a report detailing my child's results. If my child has Medicaid and therapy is recommended, I authorize an evaluation and any subsequently recommended therapy services to be provided at my child's learning center. I authorize SPEECH READS THERAPY to discuss concerns, treatment, diagnoses, and test results with collaborating professionals, including my child's pediatrician, therapists, teachers, and other healthcare providers when such collaboration may benefit my child. I authorize SPEECH READS THERAPY to share medical information with Medicaid as necessary for determining eligibility and processing claims. I consent to SPEECH READS THERAPY billing Medicaid and receiving payment of government benefits for services provided. I understand that SPEECH READS THERAPY will not bill me or my private insurance without further discussion regarding the recommended treatment plan.I acknowledge the following: Screenings are free.Screenings are voluntary. SPEECH READS THERAPY recommends contacting my child's Primary Care Manager (PCM) before utilizing any services.I understand that my child's information will be maintained in accordance with applicable privacy laws, including HIPAA, and that I may request a copy of the Notice of Privacy Practices at any time.