Authorization of Release of Information

Authorization of Release of Information
Completion of this form will serve as written permission for Bayside Pediatric Therapy to communicate with the individuals you have listed below for the purposes you identify. This authorization will be considered valid throughout the course of treatment unless otherwise requested by the patient and/or guardians.
Child's Name

First Name Last Name
I authorize release of information by Bayside Pediatric Therapy to (list names
and contact information of individuals):
First Name   Last Name
First Name   Last Name
First Name   Last Name
First Name   Last Name
Pediatrician:   First Name   Last Name
For the purposes of

Coordinating services, techniques, treatment strategies among other professionals (school personnel, pediatricians, audiologists, etc.) Updating progress towards goals Providing continuity of services (relocation, change of service provider) Other
Communication to/from these individuals may occur in a variety of ways (in person, phone conversations, texts, email, fax transmittals, etc.) and may include information from the patient’s medical record, for example, speech
Signature

Clear
Should be Empty: