BCFH - Permission to Obtain & Release Information Form (New)

Permission to Obtain & Release Information Form
This information is entirely confidential

To best serve your child and family, it may be necessary to obtain information from and share information with other individuals or agencies who are involved with your child. Information to be shared is limited to what is necessary to enable us to work effectively with you and your child (e.g. goals, observations, assessments, reports, etc.)

In order for us to request, receive or share information, please:
- Read and sign below.
- Check the boxes for each service provider you are receiving services from, and fill in any name/contact information you have about them.
Name of child*

First NameLast Name
Date of Birth*
Please give us the name of the Early Interventionist working with your child at BC Family Hearing Resource Society. If you don't know the name, please just pick "I don't know":*
By signing below, I hereby give permission for verbal or written information to be released to and obtained from the following individuals and agencies to the BC Family Hearing Resource Society:
Name of Legal Guardian*

First NameLast Name
Phone Number*

Area CodePhone Number
Today's Date

MonthDayYear
Date
Signature*
In order to quickly provide information and reports to you or other professionals providing service to your child, we sometimes use email or fax. We take precautions using email and fax in an attempt to protect your privacy. However, you need to be aware that faxing or emailing information does include the risk of personal information being accidentally disclosed to other people (e.g. on the web). For this reason we need your permission to send reports through email or fax.
Do you authorize us to send reports and information on your child through email or fax?*

Yes, I give my permission to send reports on my child through email or fax.No, I do not give permission to send report on my child through email or fax. All reports must be sent through the mail.
Today's Date

MonthDayYear
Date
Signature*
This authorization will expire 12 months from the date of this signature,
or sooner at family’s request.
Please give us information on those who provide services to your family. Click on the options of service providers that apply to your family. Information fields will then appear below the list.

If you do not know a particular piece of information for a service provider, enter "N/A" or "I don't know" in that field. If the piece of information you don't know is the phone number, enter "000" for the phone number field.
Have you used, are currently using, or will use any of these services in the near future? (Select all that apply):*

BC Children’s HospitalOther HospitalBC Early Hearing ProgramCommunity AudiologistDeaf Blind Early Intervention ProgramENT (Ear, Nose, Throat) SpecialistFamily DoctorPediatricianOther DoctorFoster ParentInfant Development ProgramOccupational TherapistPhysiotherapistPreschool/DaycareSchool District/Prov. Resource ProgramSign Language ServicesSpeech Language PathologistSunny Hill Health CentreSupported Child Development
Name of BCCH provider:Name*
Address:Address*
Phone: Phone Number*
Name of BC Early Hearing Program provider:Name*
Address:Address*
Phone: Phone Number*
Name of Community Audiologist:Name*
Address:Address*
Phone: Phone Number*
Name of Deafblind Early Intervention provider:Name*
Address:Address*
Phone: Phone Number*
Name of ENT (Ear, Nose, Throat) Specialist:Name*
Address:Address*
Phone: Phone Number*
Name of Family Doctor:Name*
Address:Address*
Phone: Phone Number*
Name of Pediatrician:Name*
Address:Address*
Phone: Phone Number*
Name of other doctor working with your family:Name*
Address:Address*
Phone: Phone Number*
Name of Foster Parent:Name*
Address:Address*
Phone: Phone Number*
Name of Infant Development Program provider:Name*
Address:Address*
Phone: Phone Number*
Name of Occupational Therapist:Name*
Address:Address*
Phone: Phone Number*
Name of Physiotherapist:Name*
Address:Address*
Phone: Phone Number*
Name of Preschool/Daycare:Name*
Address:Address*
Phone: Phone Number*
Name of School District/Provincial Resource Program:Name*
Address:Address*
Phone: Phone Number*
Name of Sign Language Services Provider:Name*
Address:Address*
Phone: Phone Number*
Name of Speech Language Pathologist:Name*
Address:Address*
Phone: Phone Number*
Name of Sunny Hill Health Centre provider:Name*
Address:Address*
Phone: Phone Number*
Name of Supported Child Development provider:Name*
Address:Address*
Phone: Phone Number*
Name of Hospital provider:Name*
Address:Address*
Phone: Phone Number*
Do you receive services from any other service providers not listed or not falling into the categories above?*

YesNo
Please enter the information for these other service providers below:*
Should be Empty: