Consent & Release of Information

For best results, please fill this form out on desktop or laptop instead of a mobile device.

Please fill this out – no matter what insurance carrier you have – so that in the event of needing to default to a Teletherapy session we are covered. If you have a commercial insurance please cross out GA MED and write your carrier and policy number on the line. Please write “speech therapy” on the line under PURPOSE. Then just sign and date the bottom.

Consent & Release of Information v2***

Child Name*
DOB*
MM slash DD slash YYYY
Is there another child to add?
- Yes
- No
Second Child Name*
Second Child DOB*
MM slash DD slash YYYY
Parent/Guardian Name*
Is there a second Parent/Guardian to add?*
- Yes
- No
Parent/Guardian #2 Name*
I have read the Welcome Letter.*
Read Welcome Letter (opens in new tab/window).
- Yes
- No
I understand that Advantage Speech Therapy Services will BILL MY INSURANCE COMPANY but that any unpaid balances are my responsibility whether denied, partially paid, or not covered by my insurance company. I also understand that all balances owed are to be paid within two weeks of receipt of invoice. There is a minimum of a $30 charge for any returned checks.*
- Yes
- No
I understand that I may be INVOICED FOR A CO-PAY, TRAVEL OR AS A PRIVATE PAY CLIENT for services in full. I understand that all payments must be paid within 2 weeks of receipt of invoice.*
- Yes
- No
I give consent to have Advantage Speech Therapy PROVIDE SPEECH THERAPY SERVICES to my child.*
- Yes
- No
I give consent for my child’s PICTURE/VIDEO to be taken (no names) to be used for social medial and marketing materials.*
- Yes
- No
I agree to allow Advantage Speech Services to OBTAIN, RELEASE, DISCUSS AND/OR EXCHANGE PERTINENT INFORMATION about my child with other therapists and/or medical professionals in order to best treat my child.*
- Yes
- No
I have read and understand the Consent & Release terms. I understand that missed sessions will be invoiced from the credit card on file, delinquent accounts will be charged to credit card on file, and credit card fees will apply to any invoices.*
- Yes
- No
I understand that unpaid invoices will be charged to the credit card on file with processing fees added.*
- Yes
- No
Signature Parent/Guardian #1:*
Signature Parent/Guardian #2:*
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Who is ASTS?

Robyn M. Drothler M.ED. CCC-SLP
Alpharetta, GA

P: (404) 784-1252
F: (678) 624-9599

Give us a Call

(404) 784-1252

Send us a Message

robyn@advantagespeech.com

Resources

ASTS Forms
Common Questions
Speech Therapy FAQs
Contact Us

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Opening Hours

Monday09:00 - 05:00
Tuesday09:00 - 05:00
Wednesday09:00 - 05:00
Thursday09:00 - 05:00
FridayBy Appointment Only
SaturdayCLOSED
SundayCLOSED