Consent to Release Form

Consent to Release/Obtain Information/
Payment/Treat/HIPAA

    I have been informed of the use and release of information collected through services received in regards to:

    Patient’s full name

    I request that copies of Information in regards to my child be released to/from: Connected Kidz, LLC.

    Name of Child’s Doctor

    Name of Parent/Guardian

    Name of Other Doctors

    School-if Appropriate

    If appropriate

    Email Address

    I request that payment of authorized Medicaid and third-party-payer’s benefit be made to Connected Kidz, LLC for services furnished to me. I authorize them to release any medical information about me that may be needed to determine these benefits payable for related services. I understand that I will not be billed for any Medicaid services furnished to me which were billed to Medicaid during the time I had Medicaid coverage for those services.

    I consent to have my child treated by Connected Kidz, LLC for Occupational and Physical Therapy Services.

    Patient/Guardian Signature

    Date

    Witness Signature

    Date