* ALL AREAS MUST BE COMPLETED FOR BILLING PURPOSES. WE ARE UNABLE TO BILL INSURANCE/MEDICAID WITHOUT THIS INFORMATION.

IF THEY ARE NOT COMPLETED YOU WILL BE BILLED.

In case of an emergency where we are unable to contact you, this page will be given to emergency personnel. Please fill out all spaces and note any other comments we may need to know.

Who do we contact in case of emergency?

2070 McKenzie St., Suite C Springdale, AR 72762 5507 Walsh Lane, Suite 102 Rogers, AR 7758 Phone: 479.750.7778 Fax: 479.750.7708 e-mail: jarvispediatric@sbcglobal.net

Please review the financial agreement for our practice. By signing this letter you are agreeing to all the terms in it. I authorize payment of medical benefits to be made directly to Jarvis Pediatric Therapy, Inc. for services rendered. I understand that while insurance may cover some of my expenses, I will be personally responsible for anything not handled by my insurance. I understand that it is my responsibility to understand the coverage and limitations of my insurance. I agree to either fully pay or set up a payment plan and begin payment for all charges within 30 days of the receipt of my child’s patient statement. Failure to pay outstanding balances will result in additional charges for collection and/or attorney’s fees.

I understand that:

• I am entitled to a copy of this form A copy of the permission form is as valid as the original

• I may revoke this authorization at any time by notifying Jarvis Pediatric Therapy, Inc. in writing.

• This will not affect any action Jarvis Pediatric Therapy, Inc. took in reliance on this authorization before it was revoked.

• If I refuse to authorize disclosure of my child’s unrelated healthcare information, then Jarvis Pediatric Therapy, Inc. will not deny services.

• Once information is released to a third party, according to this authorization, Jarvis Pediatric Therapy, Inc. cannot prevent its re-disclosure.

• This authorization does not limit the ability of Jarvis Pediatric Therapy, Inc. to use or disclose my child’s health information as otherwise permitted by state and federal law.

• Disclosed health information may be oral or written.

I am entitled to a copy of this form A copy of the permission form is as valid as the original

When did the child ____

Can the child

There are 9 areas listed below that are commonly addressed in speech therapy. Check the areas you believe your child is having difficulty with. Check each characteristic that applies to your child within each area. Be as descriptive as possible in the ‘other’ section of each area. If there is an asterisk (*) next to an area you circled, there may be additional paperwork needed from you regarding specific concerns. This information will help the Speech-Language Pathologist in assessing and treating your child efficiently and effectively. If your child is ten years or older, you must provide the clinic with a recent IQ test before they can be evaluated for speech.

Scoring: Use an “X” to mark items that apply to your child. Mark “XX” on items which are areas of particular concern to you. Use “P” to mark items that used to be a problem, but now is resolved.