Families and Patients | Pediatric Home HealthCare North Carolina

Consent for Treatment Form

Consent for Treatment

Please take a moment to fill out the form.

Child's Full Name

Child's Birthday

Physician Name/Number:

give my consent for Life Touch Therapy, PLLC to:

Parent/ Guardian First and Last Name

(A) provide evaluation, treatment, and consultation, and

(B) disclose any personal health information including:

Check all that apply

Pediatric Therapy Evaluations

Individualized Family Service Plans (ISFP's)

Progress Reports/Notes

Other

for the purpose of treatment, payment, and healthcare operations.

I request the following limitations:

Please sign here to consent that we can bill your insurance for services. Patient agrees to pay all co-payments, deductibles, co-insurances, and balances due. Patient understands and agrees that he/she will be charged the standard LTT rates for all services not covered by a Payor.

Today's Date:

I understand that I can discontinue this consent at any time. This consent is effective until the date of discharge from services. I fully understand this form and give my consent.

Your Signature

Relationship to Child

Select a date

Thanks for submitting!

Consent for Treatment Form

Consent for Treatment

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