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.
I authorize release of information by Bayside Pediatric Therapy to (list namesand 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
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