Authorization for Release of Patient Information Form

Authorization for Release of Patient Information
Staying in communication with your child’s team of care providers allows our clinicians to provide the best collaborative care possible! Please use this form to list any providers with whom you would like your child’s clinician to communicate (physicians, teachers, care providers, other therapists, etc.) If you would like a copy of your child’s evaluation report to be sent to your child’s pediatrician, please be sure to list them on this form!

I hereby authorize The Boston Ability Center to release and request any medical or school related information as requested below.
Patient's Name

First NameLast Name
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient's Home Phone Number

Area CodePhone Number
Date of Birth

MonthDayYear
Date
Boston Ability Center has my permission to _________ information of the above name patient with the facility or person(s) listed below.

Release and Request
Person/Facility 1
Person/Facility 2
Person/Facility 3
Information will not be released without a valid signature below. This authorization grants permission for the release of information until the minor's age of majority. I can however, cancel this authorization in writing at any time, except to the extent that the Boston Ability Center has relied on it. For example, if I cancel after the Boston Ability Center has sent requested records, the Boston Ability Center will not retrieve those records. Please notify in writing if you wish to cancel the future release of information.
Signature of Parent/Guardian

Clear
Printed Name of Parent/Guardian

First NameLast Name
Date

MonthDayYear
Date
Should be Empty: