Fundamental Therapy Solutions
OKLAHOMA New Patient Intake Form

Authorization

Authorization for release of patient information

I hearby authorize ____________ to disclose my child's health information. (Please list a physician/facility name if applicable)

Please select from the following items that may be released to the physician/facility listed above: (If applicable)

Authorization for communication of patient information between School and FTS

Do you authorize FTS to communicate with your child's school and/or teachers regarding assessments and progress (if applicable)?

If yes, please list the school name:

Please select from the following items that may be released to the school listed above:(If applicable)

Current classroom performance and/or behavior

Educational or Therapeutic progress

Speech/Language evaluations, reports, & recommendations

Occupational evaluations, reports, & recommendations

Physical Therapy evaluations, reports, & recommendations

School Release: I understand that this authorization is voluntary and I may refuse to sign this authorization. I understand that authorization will expire by law, 180 from the date of signature unless I otherwise specifiy. I understand that I may revoke thisauthorization by contacting Megan Atterberry at FTS. The revocation must be in writing.

Clear

Attendance Policy Agreement

Patients may be dropped off for sessions with the understanding that parents/guardians must return at least 5 minutes prior to the end of session.

Clear

Financial Agreement

The financial agreement is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are bound to abide by such restrictions. I have been provided a copy of the FTS privacy practices and have been given a chance to read it and ask questions.

Clear

Consent for Student Observers

I consent to student observers being present during my child's therapy session. I understand that my child's primary therapist will be present and the student observer is only in the room for observation purposes.

Yes