A GUIDE FOR PARENTS

I HAVE READ, UNDERSTAND AND AGREE TO PEDIATRIC COMMUNICATION SOLUTIONS INC.’S POLICIES AND PROCEDURES.

As the legal guardian and guarantor on the account, I authorize Pediatric Communications Solutions, Inc. to charge my credit / debit card entered for charges associated with the evaluation, therapy sessions and no-show fees. I understand that my payment information will be securely saved in my file for future payments.

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. I authorize PCS to utilize the following communication methods with me.