AUTHORIZATION FOR RELEASE OF INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION
Anniel Nagler, MSPT
Pediatric Physical Therapist
Phone: (954) 648-7819
Fax: (954) 231-0799
FUNdamental Therapy Inc
4106 North 48th Avenue
Hollywood FL 33021
anniel@funtherapyinc.com
Patient ID:
Child's Name:

First NameLast Name
Birthdate:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent's Name:

First NameLast Name
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician/Agency Name:
Clinic/Agency:
Authorization Valid:
Name of Physician/Agency/Organization:
Authorization/Request to Release and/or Receive the Following Information:

Other
I give my permission to my child's Physician/Agency/Organization to contact Anniel Nagler, MSPT with Fundamental Therapy Inc. regarding all care for the purpose of providing the appropriate services and continuity of care.
Parent's eSignature:
Date:

YearMonthDay
4 digit year, 2 digit month, 2 digit dayDate
Time:

Hour Minutes
Should be Empty: