Privacy Forms

Assignment of insurance Benefits

This form gives us permission to bill your insurance benefit for the services that FIPP provided to your child or family.

Revocation of Consent Form

This form is used to withdraw permission that was previously granted. When completing the Consent Revocation Form, indicate which consent(s) are/is being revoked.

​FIPP Enrollment Forms

Below are the forms the Family, Infant and Preschool Program uses to get your consent for treatment and records and to inform you of your rights to privacy. Please complete this paperwork with your assigned early childhood intervention practitioner. The information you provide is secure and is transmitted directly to your intake and referral coordinators. If you would prefer to complete paper copies of these forms, please call our office at 828-433-2661.

Withdrawing Permission Form

Financial Forms

Notification of Verification of Income

This document is a printable guide for families that explains the ways in which FIPP is authorized to determine income for the purpose of determining a family's fee on the sliding scale.

Permission to Evaluate/Screen

This form authorizes FIPP to conduct specific developmental evaluations and screens to monitor your child's progress. If indicated, your service provider will recommend specific evaluations or screenings. We will not conduct any of the evaluations on this list without your permission.

Evaluation/Screening Form

Fee Reimbursement Policy

This form gives us permission to bill Medicaid on your behalf for the allowable services provided by our early childhood intervention team. This form is only used if FIPP will bill Medicaid for the services provided.

Consent to Use and Disclose Health Information for Treatment

This form gives us permission to provide treatment to your child and use the information you provide to obtain payment for the treatment.Type your paragraph here.

To receive paper copies of these forms, please call 828-433-2661.

Acknowledgment of Receipt of Notice of Privacy Practices

After you have reviewed our Notice of Privacy Practices with your service provider or other FIPP personnel, please use this form to acknowledge that you have done so. If you would like a copy of the Notice of Privacy Practices mailed to you, let your service provider know.

Notice of Privacy Practices

Use this link to access the FIPP/JIRDC Notice of Privacy Practices. Once you have reviewed our privacy practices with your service provider, sign the document below to acknowledge that you have received our Notice of Privacy Practices and have been provided the opportunity to ask questions.

Image Release

This form authorizes FIPP personnel to collect and use your photograph or video in publicity materials including fliers, brochures, displays, and the program's website. Images are used to publicize FIPP programs, recruit families and professionals, and demonstrate FIPP therapies and supports during training events for other professionals.

Frequently Asked Questions Regarding Costs for Services

This document is a printable guide for families to understand how fees for FIPP services are determined.

Authorization to Disclose Health Information

This form authorizes us to be in contact with another professional on behalf of your child or family through conversation or exchange of records. We routinely ask families to grant us permission to talk with the child's medical professionals and obtain health records. Families may also be working with other agencies they wish for us to be able to talk with. A separate form must be completed for each agency or professional for which consent is given. This form can be filled out as many times as needed.