Release of Protected Health Information

Client Name: First Name* Last Name* Client DOB: Client DOB*  
Client's SS#:   Optional    

I hereby authorize Early Bird Developmental Services, LLC and the following agencies   With whom can we share your info?*  
to share information from the health records of the above named client for evaluation and or treatment or for coordination of care.

Documents to share might include any or all of the following:

Social and Developmental History   
Physical or Occupational Therapy Evaluations and Plans of Care   
Speech-Language/Feeding Evaluations and Plans of Care  
Educational Evaluations   
Developmental/Multi-Disciplinary Evaluations  
Individualized Family Service Plans (IFSPs)  
Demographic information including insurance   
Progress Reports/Progress Notes   
Intermediate Assessments   

Other:   Other   
Other:   Other    

I request the following limitations:   Limitations   

I understand that this authorization is valid for this course of care. I also understand that I can revoke this authorization at any time with notice to Early Bird office.
       

PRINTED NAME: First Name*   Last Name*   

 (Relationship to Child):    blanks*