CONSENT FOR TREATMENT
I am aware that my child has has a diagnosis requiring speech therapy, voluntarily consent to such care for the aforementioned child by CommuniCare Therapy Services, Inc. as may be beneficial in the professional judgment of this child’s therapist.
RELEASE OF TREATMENT
CONSENT FOR PAYMENT
I authorize CommuniCare Therapy Services, Inc. to bill my insurance company for direct reimbursement of therapy services rendered to my child. Benefit payment will be assigned directly to CommuniCare Therapy Services, Inc. c/o Lisa Lester. I understand the Medicaid r ate will be accepted and billed if Georgia Medicaid covers my child. If I am not covered by Georgia Medicaid, I will be charged a maximum of $250 for Speech Therapy Evaluation and $150 for any Speech Therapy Treatment not covered by my insurance company.I understand that I am responsible for payment for any service rendered to my child not covered up to the rates mentioned above.