Evaluation Release of Information & Insurance Form

Please complete this form to allow us to consult, receive and release information to other professionals that you authorize. You can optionally include the details of your insurance plan below so that we have them on file. Otherwise you can leave that section blank.

Release of Information

Child's First Name *
Middle Name
Last Name *
Date of Birth *
As the parent or legal guardian of the above-referenced child, I do hereby declare that I am legally responsible for this child. I do hereby request and authorize Communication Apptitude and all of its employees and contractors concerning the child's records in any or all of the following instances checked below:
Check any that you agree to:
Consult with independently contracted diagnosticians and therapistsConsult with medical professionalsTalk with your insurance companyRelease reports to professional of your choosingReceive all relevant reportsConsult with school personnelObserve your child at school when requestedOther
Other
I have read the above and understand my choices for receipt and distribution of information and materials.
Digital Signature *
Today's Date *

Insurance Plan (Optional)

Subscriber Details

First Name

Middle Name

Last Name

Subscriber Date of Birth

Relationship to Child

Employer

Insurance Details

Subscriber Insurance Policy Number

Group Number

Insurance Carrier

Insurance Carrier Phone

Assignment & Release

I, the undersigned, certify that I (or my dependent) understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the therapist to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

Digital Signature

Date

Verification

Please enter any two digits *Example: 12
This box is for spam protection - <strong>please leave it blank</strong>: