* Required Information

CONSENT FOR TREATMENT OF A MINOR

As parent and/or legal guardian, I authorize FIRST STEP THERAPY to treat and/or evaluate my child.

CONSENT FOR BILLING

I understand that I am responsible for all charges incurred for therapy services provided for my child, regardless of insurance coverage. I understand that FST bills my personal insurance carrier as a courtesy and that I am responsible for the bill. I am responsible for keeping FST up to date on any changes to my plan or policy.

I understand that if my insurance carrier does not remit payment First Step Therapy within 60 days, the balance owed will be due in full from me.

CONSENT FOR RELEASE OF INFORMATION

, give permission for Pediatric.

First Step Therapy to exchange information on child . By signing this form, I understand that First Step Therapy may contact the persons or agencies (i.e. physician, other therapy agencies, school programs, etc.) listed below to obtain more information on my child, such as reports or evaluations. In addition, First Step Therapy may contact and send copies of goals, reports and other pertinent information to the agencies/individuals listed below.



ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I acknowledge that I have received the Notice of Privacy Practices (Notice). The Notice describes, in accordance with the HIPAA Privacy Regulations, how FST may use and disclose my child’s protected health information to carry out treatment, payment or health care operations and for the other specific purposes that are permitted or required by law. The Notice also describes my rights and FST duties with respect to protected health information about my child.

CONSENT FOR ADHERING TO PTN ATTENDANCE AND MAKE-UP POLICIES

The enclosed documents on FST illness, attendance and make-up policies outline many important guidelines for successful participation in therapy programs. I verify that I have read these policies and agree to abide by them.

CONSENT FOR PARTICIPATION WITH THERAPEUTIC EQUIPMENT

Intervention programs at FST usually involve the use of specialized equipment such as suspended equipment and various swings, bolsters, inflated therapy balls, climbing structures, hanging bars, tactile media (such as soap foam, Play-Doh and lotion), and a variety of other activities that involve fine, gross and oral motor coordination. Therapy activities often involve encouraging the child to try new things in ways that are challenging in order to foster increased skills and abilities. While FST staff makes great efforts to ensure each child’s safety, the nature of the therapeutic intervention includes the risk of falling, bumping into other people/equipment. I am aware of the inherent risk of this type of activity, and I give permission for my child to participate in therapy as described.

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