Release of Protected Health Information
I understand that AT&R, CST, Boom Therapy Group, Kidology Inc, and Pediatric Therapy Associates will only disclose my protected health information for treatment purposes or obtaining payment for therapy services. I acknowledge this use and disclosure of my personal health information by signing below. I hereby authorize the mutual exchange of information regarding the above named person between the company, the child's primary doctor and any other individuals or agencies listed below.This patient's information may be used by the person(s) and/or agencies I authorize for medical treatment, consultation, billing, or other purposes. This authorization shall be in force and effect while patient is being treated by the company. I understand that I have the right to revoke this authorization in writing at any time.
If a pediatric patient, legal guardian's name and relationship:
Please list individuals &/or organizations that you would like us to discuss/release protected health information regarding:
Date of signature:
Should be Empty: