Release of Information

Caterpillar Playground Occupational Therapy Release of Information

HIPAA Waiver
Date*

MonthDayYear
Date
Name of Child*

First NameLast Name
Name of Parent / Guardian*

First NameLast Name
Child's Date of Birth*

MonthDayYear
Date
Age
Please list all providers or contacts with whom you wish to authorize Caterpillar Playground to discuss your child's care at this time. We will request additional release forms as needed.
Provider/Contact Name*

First NameLast Name
Organization Name

First NameLast Name
Provider Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Provider Email*
example@example.com
Provider Address

Practice / Company Name

Street Address

CityState

Zip CodeCountry
YesNo
Provider 2 Name*

First NameLast Name
Provider 2 Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Provider 2 Email*
example@example.com
Provider 2 Organization Name

First NameLast Name
Provider 2 Address

Practice / Company Name

Street Address

CityState / Province

Postal / Zip Code
I am allowing the release of all health recordsI am allowing the release of health records for services which occurred within the following period:
Date From

MonthDayYear
Date
Date To

MonthDayYear
Date
Occupational Therapy Evaluation and TreatmentMedical HistoryMental Health HistoryOther
Coordination of careSchedulingBilling / PaymentTherapeutic collaboration (may include other therapists, teachers, care providers, or medical professionals)Transfer of care to another providerReferral for additional servicesOther
One year from todayDecember 31st of current calendar year30 days following end of services with Caterpillar Playground
By signing this form, I understand and acknowledge that I may revoke this waiver at any time in writing. However, in cases where disclosures were already been made prior to revocation, I understand that such revocations may not be taken back. Under the HIPAA Privacy Standards, I understand that parties who are not a party to this agreement may possibly redisclose the information. I understand that this disclosure is not mandatory and I may choose not to sign this waiver. I understand this waiver may not be conditioned upon a treatment. I understand that upon submission of this waiver, I will receive a copy. The copy that I receive shall be deemed an original.
Signature of Parent/Guardian/Representative*

Clear
Signature of Parent or Guardian
Should be Empty:

Caterpillar Playground Occupational Therapy Release of Information