Blog | Pediatric Communication Solutions

September 29, 2025Uncategorized

Pediatric Communication Solutions, Inc. (PCS) is committed to providing a safe, supportive, and welcoming environment for all of our children, parents, students, and staff. To ensure safety and comfort for all we expect all individuals to act in a mature and responsible way that respects the rights and dignity of others. This applies to all […]

How Families Access Pediatric Therapy Services

June 27, 2025Parental Resources

Understanding Pediatric Therapy Access Accessing pediatric therapy services can be a critical step for families seeking support for their children’s developmental, physical, or behavioral needs. This article explores how families can effectively obtain these services, the types of therapies available, the processes involved, and the resources that can guide parents and caregivers through every stage […]

How Parents Can Track Progress in Therapy Sessions

June 26, 2025Parental Resources

Understanding Your Role in Tracking Therapy Progress Parents play a crucial role in their child’s therapy journey by actively monitoring and supporting progress. Therapy is often a complex, non-linear process that requires patience, consistent observation, and collaboration with professionals. This article provides comprehensive guidance on how parents can effectively track their child’s progress through various […]

The Benefits of Comprehensive Evaluations for Kids

June 25, 2025Parental Resources

Understanding Comprehensive Evaluations for Children Comprehensive evaluations are critical tools designed to examine children’s educational, psychological, and developmental needs in depth. These evaluations are more than simple tests; they combine standardized assessments, detailed observations, family and school history, and expert analysis to unveil a clear picture of a child’s strengths and challenges. Understanding what comprehensive […]

Choosing Between Private and School-Based Speech Therapy

June 24, 2025Parental Resources

Understanding the Choices in Speech Therapy When children need speech therapy, parents often face the decision between private and school-based services. Each option offers unique benefits tailored to different needs, goals, and circumstances. This article breaks down the differences and considerations to help families make informed decisions that best support their child’s communication development. Key […]

How Speech Therapy Helps Children Succeed in School

June 23, 2025Parental Resources Speech & Language Disorders

Understanding the Crucial Role of Speech Therapy in Education Speech therapy is a vital resource that supports children’s academic success and overall development by improving communication skills essential for learning and social interaction. This article explores how speech therapy, facilitated by skilled speech-language pathologists, empowers children to overcome communication challenges, enhance literacy skills, and gain […]

What Parents Should Bring to a Speech Evaluation

June 20, 2025Parental Resources Speech & Language Disorders

Getting Ready for Your Child’s Speech Assessment A speech evaluation is a crucial step in understanding and supporting your child’s communication development. Preparing effectively can make the process smoother and more beneficial. This article outlines what parents should bring to a speech evaluation, how to prepare, what happens during the assessment, and what to expect […]

The Role of Speech Therapy in Child Development

June 19, 2025Parental Resources Speech & Language Disorders

Understanding the Intersection of Speech Therapy and Child Growth Speech therapy is a powerful tool in supporting children’s communication and overall developmental progress. This article explores how targeted speech therapy interventions can transform language acquisition, social skills, and cognitive abilities, setting a strong foundation for lifelong success. By recognizing key signs, implementing early intervention, and […]

Literacy Support for Bilingual Children

June 18, 2025Reading and Writing

Why Literacy Support Matters for Bilingual Children Bilingual children navigate unique challenges and benefits on their path to literacy. Understanding how language development, cognitive skills, and cultural context interplay offers educators and families powerful tools to foster biliteracy. This article explores key research findings, effective strategies, essential resources, and the developmental advantages bilingualism provides in […]

NEW PATIENT INFORMATION PACKET

"*" indicates required fields

Location*

929 E. Britton Rd
Oklahoma City, OK 73114

4331 Adams Rd
Suite 111
Norman, OK 73069

PATIENT INFORMATION

Patient First Name*

Middle Initial

Patient Last Name*

Date of Birth*

Gender*

Male

Female

Patient's SSN#

Patient's Preferred Language*

PARENT / LEGAL GUARDIAN INFORMATION

Parent / Legal Guardian's Address*

Street Address Address Line 2 City State ZIP Code

Parent / Legal Guardian*

First Last

Parent / Legal Guardian's Phone #1*

Occupation

Parent / Legal Guardian's Email*

Parent / Legal Guardian

First Last

Parent / Legal Guardian's Phone #2

Occupation

Does the child live with both parents?

Yes

Since you selected 'No,' with whom does the child live?

Siblings (name & ages)

INSURANCE INFORMATION

We will need a copy of the insurance card in order to file a claim.

Insurance or Self-Pay?*

Insurance

Self-Pay

Primary Insurance Company

ID#

Group#

Policy Holder*

First Last

Policy Holder's Relationship to Patient

Policy Holder's Date of Birth*

Policy Holder's SSN#*

Policy Holder's Employer

I have a secondary insurance.

YES

Secondary Insurance Company

ID#

Group#

Policy Holder

First Last

Policy Holder's Relationship to Patient

Policy Holder's Date of Birth

Policy Holder's SSN#

Policy Holder's Employer

CASE HISTORY

Referring physician/pediatrician NAME

Referring physician/pediatrician PHONE

Specialists who have seen this child

Are there any known diagnoses? (Down syndrome, Autism, Cerebral Palsy, ADD, ADHD, etc?)

Did your child pass his/her newborn hearing screening?

Yes

Has your child had a hearing screening or evaluation within the past year?

Yes

What were the results of the hearing screening or evaluation?

Do you have any specific concerns regarding your child's hearing / ears?

Where was the evaluation performed? (Audiologist, ENT, Pediatrician's office, etc)

What is the approximate date when the hearing screening or evaluation took place?

What language(s) does the child speak?

What language(s) do the parents speak?

If the child is bilingual, which language is used and understood by the child?

What language(s) do the parents primarily speak to the child?

How does the child usually communicate? (check all that apply)

gestures

sign language

single words

phrases

sentences

Is the child’s speech difficult to understand?

Yes

Describe the child’s speech, language, fluency, voice, or hearing problem.

When was the problem first noticed and who first noticed the problem?

Is there a family history of communication disorders? If yes, who had the problem?

PRENATAL AND BIRTH HISTORY

Describe the mother’s general health during pregnancy (illness, accidents, prescription, nonprescription medications taken, etc.) Describe any unusual conditions associated with the pregnancy or birth.

Is the child adopted?

Yes

Is the child in foster care?

Yes

Type of delivery?

head first

breech

cesarean

Length of pregnancy

Length of labor

Child’s general condition at birth

Birth weight

DEVELOPMENTAL HISTORY

Please list the approximate AGE your child achieved these developmental communication milestones:

babbled

use of gestures

first word

2-word phrases

simple sentences

Please list the approximate AGE your child achieved these developmental motor milestones:

sat alone

crawled

fed self

walked

toilet trained

CURRENT SPEECH, LANGUAGE, & HEARING

Does your child understand what you are saying?

Yes

Sometimes

Does your child retrieve/point to common objects upon request?

Yes

Sometimes

Does your child follow simple directions?

Yes

Sometimes

Does your child respond correctly to yes/no questions?

Yes

Sometimes

Does your child respond correctly to who/what/where/when/why questions?

Yes

Sometimes

Does your child have difficulty producing speech sounds?

Yes

Sometimes

Does your child frequently stutter when trying to speak?

Yes

Sometimes

Does your child communicate with words more often than gestures or crying?

Yes

Sometimes

Does your child speak in 2-4 word sentences?

Yes

Sometimes

Does your child make eye contact with you/other people?

Yes

Sometimes

Does your child become easily distracted?

Yes

Sometimes

Check all behavioral characteristics that describe your child:

MEDICAL HISTORY

My child is allergic to (select all that apply):

My child has no food allergies

My child has seasonal allergies

Tree nuts

Peanuts

Eggs

Soy

Dairy

Shellfish

Other

Child's general health is:

Good

Fair

Poor

Please describe any major accidents, surgeries, or hospitalizations the child has had since birth.

Please list the child’s current medications, dosages, and frequency of dosage.

EDUCATIONAL HISTORY

School or Preschool

Grade

Does your child have an:

IEP

IFSP

How is your child doing in school?

Does your child attend Daycare?

Yes

Does your child attend a Mother’s Day Out program?

Yes

ADDITIONAL INFORMATION

Please add any additional information you feel might be helpful in the evaluation or treatment of your child.

PEDIATRIC COMMUNICATION SOLUTIONS, INC. POLICIES AND PROCEDURES

POLICIES & PROCEDURES

CODE OF CONDUCT
Pediatric Communication Solutions, Inc. is committed to providing a safe, supportive, and welcoming environment for all of our children, parents, students, and staff. To ensure safety and comfort for all, we expect all individuals to act in a mature and responsible way that respects the rights and dignity of others. This applies to all staff, students, parents, family members, and guests who enter our facilities. Our code of conduct does not permit language or action that intimidates, hurts, or frightens another person, or that falls below a generally accepted standard of conduct.

DISCIPLINE POLICY
Cooperation and a positive attitude of all clients is a vital component of speech language services; therefore, any violent behavior will not be tolerated.  Pediatric Communication Solutions, Inc. reserves the right to determine who is or is not suitable for speech-language services and will take all measures to provide a safe and conducive environment for learning. We support a three strikes behavior policy; however, we reserve the right to a zero-tolerance policy regarding violence. In the case of violent behavior by a child, services will be immediately terminated.
•	First offense is a verbal warning.
•	Second offense is a written warning signed by the parent and owner.
•	Third offense will be a consultation with the owner and a possible suspension or termination of services.
•	Your child can and will participate fully in speech-language services and will cooperate and accept our guidance in standards of behavior. Failure to adhere to these standards may result in suspension or termination of services.
•	We aim to provide a positive learning environment for all children, and we welcome communication with parents anytime.

CONFIDENTIALITY AGREEMENT
Pediatric Communication Solutions, Inc. understands the sensitivity of the information shared with our staff and strive to keep all information shared private and confidential. To maintain confidentiality, only general information about the individual sessions will be shared in the public areas of the clinics. If you would like to discuss the session in greater detail, our clinicians are available to speak in private during the beginning or end of your child’s session(s). All families must sign a this form acknowledging agreement to maintain confidentiality prior to participating in services at Pediatric Communication Solutions, Inc.

COMMUNICATION AGREEMENT
I consent to Pediatric Communication Solutions, Inc. (PCS) staff and its affiliates using any telephone numbers (including cell phone/wireless numbers), email addresses, and other electronic communications I provide to PCS for appointment, referral, treatment, billing, debt collection, and other purposes related to my/my child’s care. This includes phone calls, voice messages, text messages, emails, and other electronic communications. If I discontinue use of any phone number provided, I shall promptly notify PCS and will hold PCS and its affiliates harmless from any expenses or other loss arising from any failure to notify. I understand that standard text messages, unencrypted emails, and other electronic communications that I send and receive from PCS may flow through networks that are not secure and may be at risk of exposure of my health information (for example, the message could be intercepted and viewed by an unauthorized third party). In addition, once the text, email, or other electronic communication is received by me, someone may be able to access my phone, applications, digital devices, or email accounts and read the message. I understand that it is my responsibility to make sure that only authorized people are allowed to access my email, phone messages, cell phone, and digital devices. I understand these risks and give permission to PCS to communicate with me via wireless/cell phone, text message, unencrypted email, and other electronic communications.

PERSONAL BELONGINGS POLICY
Pediatric Communication Solutions, Inc. is not responsible for any lost, stolen, or damaged items while on the premises of any Pediatric Communication Solutions location.

NON-DISCRIMMINATION
It is the policy of Pediatric Communication Solutions, Inc. to maintain an environment free of all forms of discrimination and rules for acceptance and participation in speech services are the same for everyone regardless of race, color, ethnicity, religion, or gender.

INSURANCE
At Pediatric Communication Solutions, Inc. our billing specialist is committed to providing the best experience possible.  We will file your insurance claims for you, along with working with you and your insurance company to obtain payment for services.  Your insurance coverage is a contract between you and your insurance company and/or you and your employer and insurance company. Your insurance benefits for therapy services will be checked and reviewed with you in detail prior to the first appointment.  Please note that a quote of benefits are not a guarantee that therapy will be covered.  Your child’s diagnosis and treatment plan of care are unique, so never assume the benefits will ensure payment for services rendered. It is the parent/legal guardian’s responsibility to keep the office updated on any new insurance policy and provide Pediatric Communication Solutions, Inc. with an updated insurance card each year or when a new policy is obtained. If PCS is not updated on insurance changes, the patient/guarantor will be charged in full (self-pay rate) for services rendered during that time.

Reimbursement
Pediatric Communication Solutions, Inc. accepts most types of insurance as a form of payment.  Call the clinic to see if Pediatric Communication Solutions, Inc. is in-network with your insurance carrier/policy. Any co-payment/co-insurance/session deductible is due at the time of service.  If services are not covered for any reason by your insurance company, you will be responsible for payment in full.

Insurance Agreement
All members receiving services at Pediatric Communication Solutions, Inc. must agree to our Insurance Agreement. This will be completed prior to the initial evaluation. The insurance agreement is as follows.

This   Insurance   Agreement (the “Agreement”) is made and entered into between (“Legal Guardian”) and Pediatric Communication Solutions, Inc.

1.	I, Legal Guardian, must make sure the office is aware of any name, address, phone and/or insurance information changes before the appointment.

2.	I, Legal Guardian, am responsible for contacting my insurance company and understanding speech-language coverage terms before evaluation or therapy begins at Pediatric Communication Solutions, Inc.

3.	I, Legal Guardian, agree to pay for any and all medical/therapy services I receive from Pediatric Communication Solutions, Inc.  including those that my insurance company refuses to pay, for whatever reason. Pediatric Communication Solutions, Inc. will file a claim on my behalf (if contracted with my insurance company), however, if my insurance company denies payments for any reason (e.g. non-covered services, services not medically necessary, my failure to obtain a referral, etc.), I will pay these charges promptly upon written/verbal notification of this refusal. If the insurance company requests additional information for processing your claim, Pediatric Communication Solutions, Inc. will promptly comply only one time; there will be no multiple re-filing of claims. It is further understood that no appeals will be filed by Pediatric Communication Solutions, Inc. on my behalf.

4.	I, Legal Guardian, understand that failure of my insurance company to pay within 60 days of claim filing date will be considered a refusal to pay and I will be responsible for payment in full due upon receipt of notification.

5.	If your account is delinquent, your balance will be turned over to a collection agency and a collection fee of $75.00 or double your balance will be added.

DUAL INSUARANCE WAIVER (if applicable):
I UNDERSTAND THAT I MAY BE RESPONSIBLE FOR COMMERCIAL INSURANCE COPAYMENTS / CO-INSURANCE AMOUNTS IF MEDICAID DOES NOT AUTHORIZE SERVICES.  I HAVE READ, UNDERSTAND AND AGREE THAT I WILL PAY FOR SERVICES NOT COVERED BY MEDICAID.

TERMINATION / DISMISSAL POLICY
Dismissal/termination of speech and/or language services either permanently or for some specified time period, are set forth in accordance with the American Speech-Language Hearing Association Code of Ethics. The factors for dismissal/termination taken into account include: 1. Individuals shall evaluate the effectiveness of services rendered and of products dispensed and shall provide services or dispense products only when benefit can reasonably be expected. 2. Individuals shall not guarantee the results of any treatment or procedure, directly or by implication; however, they may make a reasonable statement of prognosis. Further, Pediatric Communication Solutions, Inc. has the right to terminate services at any time.

Termination and /or dismissal may occur due to:
1.	The communication disorder has been remediated or compensatory strategies have been successfully established;
2.	The individual or family chooses not to participate in treatment, relocates, or seeks another provider;
3.	Treatment no longer results in measurable benefits after multiple modifications have been attempted.
4.	Attendance has not been adequate to effectively remediate the communication disorder
5.	Multiple policies and/or procedures have been violated and terms of agreement between Pediatric Communication Solutions, Inc. and patients have not been successful.
6.	Non-compliance with treatment recommendations.
7.	Failure or refusal to pay for services.

It is strongly encouraged that clients speak with the clinician to express any concerns with treatment so that we may resolve any possible conflicts. In accordance with the ASHA code of ethics, if treatment is no longer efficacious, it will be terminated.  Pediatric Communication Solutions, Inc. will honor requests to transition services and/or make referrals or recommendations for future clinicians. Please contact our offices during business hours to make arrangements if financial situations arise.

FINANCIAL
Private Pay (Same-Day Payment Rate)
The current session rate for speech-language therapy is $100.00 per session (30 minutes). For families who pay for services on the same day they are provided, we offer a discounted rate. The “same-day payment” rate for a speech-language pathologist (SLP) is $80.00 per session.

Same-Day Discount
Payment is due in full at the time of service in order to receive our “same-day payment” discount.

Refund Policy
No refunds will be made for services (evaluations or treatment) already rendered.  If at any time, it is determined that a refund should be appropriate for a pre-payment of services that are no longer going to be utilized, the client should speak with the owner to make arrangements.

Credit Card on File Policy 
Pediatric Communication Solutions, Inc. is committed to making our billing process as simple and easy as possible, We require that all patients provide a valid credit card on file with our office. Credit cards on file will be used to pay copays when you are seen in our office, including account balances, after your insurance processes your claim.  If we do not receive payment for the amount listed on your statement within 30 days, we will run the credit card on file for the full amount owed, unless you have called to setup a payment plan. If your payment is declined, we will call you for an updated card. If our reminder call is not returned within one week, a $25 declined payment fee will be applied, and another statement will be mailed or emailed. Your account becomes delinquent if not paid within 90 days after the date of the original statement. I give Pediatric Communication Solutions, Inc. permission to charge my credit card for any patient balance due on my account. I have read a copy of Pediatric Communication Solutions, Inc. Notice of Privacy Practices. I understand a written copy will be provided to me at any time upon my request.  If you have any questions, please contact our office at 405-438-0090 or via email at office@pcs-ok.com

SCHEDULING
Patients will be required to sign up for recurring/standing appointments weekly/monthly.  Reschedules are allowed and are detailed within our attendance policy (below).  All schedule changes must be made through the front office either via phone, email, or text. Phone: 405-438-0090; email office@pcs-ok.com

ATTENDANCE / CANCELLATION POLICY
Regular attendance of scheduled therapy sessions is crucial to your child’s progress. Therefore, to better serve our growing number of patients and their families, we require everyone to follow our 85% attendance policy and respect our “24-hour cancellation” policy regarding appointment cancellations and rescheduling.

Failure to cancel or re-schedule the appointment within 24 hours of the scheduled appointment will result in a fee for a missed appointment. This fee will NOT be submitted to the health plan/insurance; it will be charged to the patient. The missed appointment/cancellation/no-show fee is $35 per therapy session and $100 for evaluations.

Our attendance policy is as follows:  All clients must maintain 85% attendance for all therapy appointments.  Three no shows for scheduled appointments results in immediate discharge.  Pediatric Communication Solutions, Inc. reserves the right to discharge patients who do not maintain 85% attendance or violate the “no show/no call” policy. Pediatric Communication Solutions, Inc. understands that unexpected circumstances can never fully be avoided, and we are more than willing to work with each of you on a case by case basis to resolve any unexpected scheduling issues that may arise occasionally. Please make sure you notify the clinic when you are unable to keep scheduled appointments. If you have any questions or need to reschedule an appointment, please do not hesitate to call the clinic at 405-438-0090. We will be more than happy to work with you.

In order for your child to continue making progress, our therapists and front office staff can work together with you to reschedule any cancelled/missed appointments.  This may mean that another therapist may see your child depending on the rescheduled time and availability. Cancellations must be made through the front desk via phone, email, or text with 24 hours advance notice whenever possible. We understand that kids get sick, and emergencies happen.  So, if 24 hours’ notice is not possible, please call as soon as you can, because we often have clients waiting to be seen who could use your child’s cancelled appointment spot. Voicemail is available for you to leave a message 24 hours a day, 7 days a week.  1 cancellation per month is allowed, as long as it is rescheduled within the following week (upon availability). We strive to provide 30 minutes of productive treatment each session.  Should your child arrive more than 15 minutes late, Pediatric Communication Solutions, Inc. reserves the right to cancel your appointment.  If there has been no phone call prior to the appointment start time, that will be counted as a no-show for that day. No-shows should happen only in the case of an emergency, since in most cases, you are able to call, email, or text to cancel an appointment. After 1 or 2 no-show appointments, our office may ask you if we can make schedule changes to better accommodate for your family. In the rare event that a child has 3 no-show appointments in one quarter, they will be removed from the schedule so that another child on the waiting list may be seen.

SICK / ILLNESS POLICY
It is the policy of Pediatric Communication Solutions, Inc. that in the event the patient becomes ill, the following guidelines will be utilized for re-admitting patients into treatments as listed below:

Cancel appointment if one or more of these conditions are present:
•	Fever of 100 degrees or above
•	Vomiting, nausea or severe abdominal pain
•	Other symptoms suggestive of acute illness

Return to Therapy Guidelines:
•	Fever free for full 24 hours without medication
•	Symptom free of vomiting, nausea or severe abdominal pain
•	All health conditions listed above have been treated and resolved

WAITING ROOM POLICY
Pediatric Communication Solutions, Inc. aims to provide pleasant, confidential, and highly individualized services. While waiting you may overhear confidential information. It is your obligation to maintain confidentiality. All participating parties agree to our confidentiality agreement (above) by signing this document prior to beginning services. Parents are encouraged to attend treatment sessions, however, if your child performs better without you in the room, or if you have other children who would cause a distraction, families are welcome to wait in our lobby during sessions. To provide effective care we ask all patrons to follow the following waiting room policies. No loud conversations or devices in the lobby.  Utilizing headphones is preferred, and if you need to take a phone call, we ask that you step outside as a courtesy to the other clients. We understand that children may have snacks with them.  We ask that you please keep the area clean and throw away any trash.  All drinks should have lids. Due to confidentiality as well as noise level and space constraints, we try to minimize time spent in the lobby.  If you would like to consult with your child’s therapist, please do so during the beginning or end of their session in the treatment room.

CREDIT CARD AUTHORIZATION FORM

Pediatric Communication Solutions, Inc. is committed to making our billing process as simple and easy as possible, We require that all patients keep a valid credit card on file with our office. Payment is due at the time of service.

CREDIT CARD TYPE*

Cardholder's Name*

First Last

Credit Card Number*

Expiration Date*

CVV Code*

Enter the 3 digit code on the back of the card

Is the billing address for the credit card entered the same as the home address entered above?*

YES

Billing Address

Enter the billing address associated with the credit card entered.

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

APPROVED COMMUNICATION METHODS:*

PHONE CALL

VOICEMAIL

TEXT MESSAGE

PATIENT LIABILITY FORM

This form is to inform you that certain speech-language pathology services may not be covered under your commercial insurance policy due to plan exclusions or benefit limitations. While we will make every effort to verify and bill your insurance appropriately, coverage is ultimately determined by your insurance provider.

THIS INSURANCE AGREEMENT (THE “AGREEMENT”) IS MADE AND ENTERED INTO BETWEEN (“LEGAL GUARDIAN”) AND PEDIATRIC COMMUNICATION SOLUTIONS, INC.*

I, Legal Guardian, must make sure the office is aware of any name, address, phone and/or insurance information changes prior to the scheduled appointment.

I, Legal Guardian, am responsible for contacting my insurance company and understanding speech-language coverage terms before evaluation or therapy begins at Pediatric Communication Solutions, Inc. Your insurance may exclude coverage for speech-language evaluations and/or therapy services based on diagnosis, medical necessity, or policy-specific limitations.

I, Legal Guardian, understand insurance verification is not a guarantee of payment. Final determination is made by the insurance company once the claim is submitted and reviewed.

I, Legal Guardian, agree to pay for all medical/therapy services I receive from Pediatric Communication Solutions, Inc. including those that my insurance company refuses to pay, for whatever reason. Pediatric Communication Solutions, Inc. will file a claim on my behalf (if contracted with my insurance company), however, if my insurance company denies payments for any reason (e.g. non-covered services, services not medically necessary, my failure to obtain a referral, etc.), I will pay these charges promptly upon written/verbal notification of this refusal. If the insurance company requests additional information for processing your claim, Pediatric Communication Solutions, Inc. will promptly comply only one time; there will be no multiple re-filing of claims. It is further understood that no appeals will be filed by Pediatric Communication Solutions, Inc. on my behalf. The current session rate is $100.00 per session (30 minutes). For families who pay for services on the same day they are provided, we offer a discounted rate. The “same-day payment” rate for treatment for a speech-language treatment is $80.00. Payment is due in full at the time of service to receive the “same-day payment” rate discount.

I, Legal Guardian, understand that failure of my insurance company to pay within 60 days of claim filing date will be considered a refusal to pay and I will be responsible for payment in full due upon receipt of notification.

I, Legal Guardian, understand that I may be responsible for commercial insurance payments / co-insurance amounts if Medicaid does not authorize services. I have read, understand and agree that I will pay for services not covered by Medicaid.

If your account is delinquent, the balance will be turned over to a collection agency and a collection fee of 30% of the account will be added.

PARENT / LEGAL GUARDIAN'S NAME*

First Last

TODAY'S DATE*