EVALUATION/TREATMENT CONSENT FORM-PlayRx

Please mark requested services below:

Speech Therapy

Occupational Therapy

Physical Therapy

Your child has been referred for a formal evaluation in the area(s) marked above. PlayRx Speech-Language Pathologist, Occupational Therapist, and/or Physical Therapist feel your child would benefit from formal evaluation and therapy services, should qualification be identified. All Consented Evaluations will be conducted by a PlayRx licensed and certified therapist in the corresponding discipline.

Child's Legal Name (First AND Last):

Child's Preferred Name:

Child’s sex

Male

Female

Child's Date of Birth:

Child’s SSN

Has your child received an Evaluation or Treatment within the past year for any therapy services? (PT/OT/or ST)

YES

Facility your child attends (daycare/pre-school/etc.):

Referral Details:

Contact Information:

Parents' Names (First and Last):

Mailing Address

Primary Phone Number and Name:

Secondary Phone Number and Name:

Email Address:

Preferred Method of Communication: Choose one

Phone Call

Text

Billing Information:

Please Check the Appropriate Choice(s) from the Following: ****If your child has ore than one coverage, please provide information on all active policies****

My Child has Medicaid, ARKids, or TEFRA Coverage:

Medicaid Number:

Social Security Number:

Name of Primary Care Physician:

Phone # of Primary Care Physician:

My Child has Health Insurance Coverage

Insurance Carrier:

Policy Number:

Guarantor Name:

Guarantor Date of Birth

Guarantor SSN

If your child has secondary insurance, please include information of the secondary insurance card below:

Insurance Carrier:

Policy Number:

Guarantor Name:

Guarantor Date of Birth

Guarantor SSN:

Primary Care Physician Information:

Name of Primary Care Physician:

Phone # of Primary Care Physician:

My Child does not have Medicaid, ARKids, TEFRA of any other insurance coverage. +PLEASE CALL FOR ASSISTANCE: (501) 819-0553

Guarantor Information (Person responsible for any payments for services):

Guarantor first and last name:

Guarantor relationship to patient:

Spouse

Parent

Other

Guarantor SSN

Guarantor Sex

Female

Male

Guarantor Date of Birth

Guarantor Address

Guarantor Phone Number

Terms & Conditions: By signing this Consent Form, I authorize PlayRx to conduct a Speech-Language, Occupational, and/or Physical Therapy Evaluation as well as provide treatment if qualification is established through testing results and oversight is agreed to by your child's primary care physician. Further, I authorize the release of any medical or other information necessary to process claims associated with services provided to my child by PlayRx. I also authorize payment of benefits to PlayRx. Signature further ensures that a copy of PlayRx's Privacy Policy has been received and reviewed. I understand that giving consent for these services is voluntary and can be withdrawn at any time.

I agree to the terms & conditions

Parent name:

Your Signature

Date