Parental Consent Form

* Form must be completed in its entirety or will not be accepted

Member Name: *

Member RID # *

Member Diagnosis *

I (print name of Member/parent/legal guardian) *

hereby authorize (print name of provider) *

to evaluate, as well as provide any subsequent treatment based on the evaluation results for (please check all services that apply) *

Physical Therapy

Occupational Therapy

Speech Therapy for child named above.

Signature of Parent/Legal Guardian if a minor

Clear

Date Signed Parent/Legal Guardian

Relationship to Member

Signature of Therapist or Representative of Therapy Group

Clear

Date Signed by Provider

OHCA Revised 3-2-16 SC-15

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