CONSENT TO RELEASE/REQUEST CONFIDENTIAL INFORMATION
To be completed, if you would like GASLC to release your records to a third party or request information from a third party
Patient Name:
*
First Name
Last Name
Agency, School, Physician, etc. whom you would like us to send the information to:
*
Address of Agency, school, physician, etc.:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of agency, school, physician, etc.:
*
-
Area Code
Phone Number
Fax Number of agency, school, physician, etc.:
-
Area Code
Phone Number
Email of agency, school, physician, etc.:
*
example@example.com
The undersigned authorizes Greater Atlanta Speech and Language Clinics, Inc. to release or request the following information to the above stated entity when such information is necessary in the therapeutic program of the patient:
*
Evaluations (including initial assessments, re-assessments, and discharge assessments)
Clinical notes for the duration of treatment
Verbal discussion regarding patient
Other
Signature
*
Parent/Guardian Name:
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: