Language
English (US)
Español
Authorization to Disclose Protected Health Information
Easterseals Pediatric Therapy
Patient Name
*
FIRST
MIDDLE
LAST
Date of Birth
*
-
Month
-
Day
Year
I hereby authorize disclosure of protected health information as follows:
Person/Organization sending the information:
*
i.e. Easterseals Pediatric Therapy, Name of Your Pediatrician/Office or Other Health Professionals, Name of Your School or Teachers, etc.
Person/Organization receiving the information:
*
Easterseals Pediatric Therapy
i.e. Easterseals Pediatric Therapy, Name of Your Pediatrician/Office or Other Health Professionals, Name of Your School or Teachers, etc.
Type of information to be used or disclosed:
*
Developmental Testing/Report
Health/Medical Records
Progress Reports
Psychological Testing/Record
Screening/Intake Information
Social/Developmental History
Speech/Language Testing/Reports
Staffing Reports, IFSPs
Therapy/Testing reports
Vision/Hearing reports
Other
I understand that:
This information is protected under federal law.
I may refure to sign this authorization.
I have the right to revoke this authorization in writing, but, if I do, it will not have any effect to the extent that Easterseals Pediatric Therapy has taken action to reliance on it.
This authorization will expire in one year from the submission date.
The above information will not be released to any other individual or agency except to the one listed above without prior written permission by the parent or legal guardian.
By signing below, I recognize that the protected health information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of this disclosure and may no longer be protected under federal law.
Treatment or payment will not be based on my signing this authorization.
Photocopies of this release form will be considered as an original.
Parent/Guardian Signature
*
Parent/Guardian Printed Name
*
First Name
Last Name
Email
*
example@example.com
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Save for Later
Submit
Should be Empty: