Medical Release Consent Form

Medical Release Consent Form
I hereby authorize and request that copies of my prior medical records related to speech/physical/occupational/feeding therapies be delivered to Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLLC to establish or continue my healthcare treatment plan. This includes the complete assessment, most recent plan of treatment, progress summary, treatment notes and any other appropriately related documents or information.

I understand that for the purpose of continuing and coordinating my plan of treatment Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLLC. may be asked to release copies of my medical records, or such portions thereof as may be relevant to evaluations or treatment services, or reports or summaries thereof, to other healthcare providers, facilities (related school or daycare staff, case managers, school system, CDSA, etc.) and appropriately related professionals involved in my care.

My signature below indicates that I hereby authorize the release and disclosure of my protected health information to the following people on an as-needed basis as determined by Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLLC. staff (choose all that apply):
Permission to Release to the following Entities or Individuals: *

Physician Inclusive Therapy Setting School Staff Related Professional Service Providers Daycare Staff Attendant Family Member CDSA Staff Custodial Foster Parent Child Care Provider Student SLP/SLP – Assistant LEA Representative
Any individuals/entities that I do NOT want my health information released to are listed specifically below:
Patient/Authorized Representative Signature
I have read and fully understand the content of this consent and authorization release and hereby agree to and authorize the foregoing provisions. As used in this document, the terms “I”, “me”, and “my” refer to and include, in addition to the undersigned, the patient named below for who the undersigned is responsible or for whom the undersigned has assumed responsibility engaging in Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeing, PLLC. to provide services to the patient.

This authorization will EXPIRE upon my discharge from patient services or upon my written request to deny future release.
Patient Name
Patient Date of Birth

Month Day Year
Signature

Clear
Printed Name
Date

Month Day Year
Relationship to Patient
Should be Empty:

Medical Release Consent Form

Patient/Authorized Representative Signature