Authorization To Disclose Confidential Information

I give permission for confidential information to be disclosed to:

Agency

Physician/Professional

First NameLast Name

Other: Name

First NameLast Name

Relationship to Patient:

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Fax

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Evaluations, re-evaluations, progress notes, medical history, consultations, discharge summaries, daily notes, patient chart, medical records

Purpose of disclosure: Continuity of care

I understand that all medical information is confidential and that patient records are the property of Beach Baby Pediatric Therapy, LLC. I will not hold Beach Baby Pediatric Therapy, LLC, including but not limited to any of its personnel, owners, employees, contractors, officers, members, agents, representatives or directors responsible for any damage, physical or mental, which may be caused by the release of patient records and the information contained therein. I further understand that the person or organization that receives the information because of this authorization may disclose this information to other people or organizations without my knowledge or consent. Therefore, I hereby release Beach Baby Pediatric Therapy, LLC, including but not limited to any of its personnel, owners, employees, contractors, officers, members, agents, representatives or directors from liability relating to or arising out of the information contained in Beach Baby Pediatric Therapy, LLC patient records.

I understand that if this authorization is for permission to disclose information to an insurance company, in order for you to obtain insurance coverage, the insurance company may still have legal right to use the information to contest your coverage.

This authorization will remain in effect from the date of signature throughout the entirety of patient care under Beach Baby Pediatric Therapy, LLC.

I understand that I have the right to revoke this authorization at any time by writing to Beach Baby Pediatric Therapy, LLC. I understand that I may revoke this authorization except to the extent that action has already been taken in reliance on this authorization.

I have read, understand and agree to all of the above information and hereby authorize Beach Baby Pediatric Therapy, LLC to release information to the above entities as it concerns:

Patient Name*

First NameLast Name

Patient Date of Birth*

Date

Parent/legalguardian Name *

First NameLast Name

Parent/legal guardian Name (signature):

Date*

Date

Hour MinutesAM/PM Option