GREENLOCK THERAPEUTIC RIDING CENTER, Inc. 55 Summer street – Rehoboth, MA 02769 Telephone:
(508) 252-5814 Specializing in hippotherapy treatment & Offering therapeutic riding
I hereby authorize:
Greenlock Therapeutic Riding Center
55 Summer Street, Rehoboth, MA 02769
to release information from the records of:
_____________________________________________________________________________________
Client Name (as appears on RI Dept of HS Medical Assistance
Card)
DOB:
__________________________________________________________________
RI Dept of HS Medical Assistance MID #:
_____________________________________
Diagnosis:
______________________________________________________________
Diag Code: (office use)
____________________________________________________
Client Address:
___________________________________________________________
State __________
zip ________________
The information to be released
upon request to Rhode Island Department of Human Services Medical Assistance
Program for the purpose of invoicing PT, OT, and/or SLP services rendered at
Greenlock Therapeutic Riding Center to above-named client are indicated below:
. Medical History
. Physical Therapy evaluation, assessment and program plan
. Occupational Therapy evaluation, assessment and program plan
. Speech Therapy evaluation, assessment and program plan
. Mental Health diagnosis and treatment plan
. Individual Habilitation Plan (I.H.P.)
. Classroom Individual Education Plan (I.E.P.)
. Psychosocial evaluation, assessment and program plan
. Cognitive-Behavioral Management Plan
. Other:
__________________________________________________________________________
This Consent for Release of Information form also authorizes Greenlock Therapeutic Riding Center to directly invoice the Rhode Island Department of Human Services Medical Assistance Program for PT, OT, and/or SLP services rendered.
Signature: ____________________________________________________
Date:
________________________________________________________
Print Name:
___________________________________________________
Relation to Participant:
__________________________________________