Rand Speech Pathology doing business as
The Joshua Tree
Children’s Speech, Occupational, Physical Therapy Services thejoshuatree.co
admin@thejoshuatree.co
I give permission for my child to receive therapy services and to file claims for these fees to medicaid on behalf of my child:
Child's Full Name
Date of birth
Medicaid ID Number
Signature:
Clear
Date:
My Relationship to Child is:
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