PATIENT REGISTRATION FORM

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

MEDICAL INFORMATION (for speech & occupational patients only)

If no, please indicate your referring physician or professional:

If there is shared custody of the child being seen, please also list the other custodial parent(s) info. below.

Please list other individuals who are involved in taking care of the patient, such as spouse, caregiver or PCA with whom you authorize Therapy Associates to discuss the patient'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, 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's illness and treatments to INSURANCE CARRIERS, PHYSICIANS, THERAPISTS, AND/OR OTHER PERSONNEL, who are involved in taking care of the patient.

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.