Authorization

I authorize therapists employed by THRIVE NC Foundation to evaluate and/or treat my child at any/all manners noted above, as prescribed by his/her physician and as deemed appropriate by the therapist. I understand that I may refuse treatment or terminate services at any time and that THRIVE NC Foundation may terminate service at any time due to noncompliance issues such as excessive absenteeism or frequent cancellation of scheduled appointments, etc.

I authorize THRIVE NC Foundation to contact my child’s insurance provider to confirm benefits and to release information necessary to process medical claims. I further authorize THRIVE NC Foundation to receive payment for any Occupational or Speech Language therapy services rendered. I understand that I may be responsible for any co-pay, coinsurance or deductible amounts associated with my child’s medical benefits, or insurance payments paid directly to me, as indicated by my insurance policy guidelines. I understand that I may, at any time, revoke this authorization in writing.

If so, I acknowledge that based upon this authorization, any actions already taken by THRIVE NC Foundation would not be affected or subject to dispute. I further understand that I may not be able to revoke this authorization if its purpose was to obtain payment. Once this office discloses health information, the person or organization that receives it may re-disclose it, which may compromise its protection under privacy laws.