• Caterpillar Playground Occupational Therapy Release of Information

    HIPAA Waiver
  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Child's Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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.

  • Format: (000) 000-0000.
  • Would you like to add another provider or organization to this release?
  • Format: (000) 000-0000.
  • Period of Allowed Heath Records Disclosure*
  • Date From
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date To
     - -
    2 digit month, 2 digit day, 4 digit year
  • Type of Health Records to be Disclosed*
  • Purpose(s) of Authorization:*
  • This authorization expires:*

  • 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.

  • Should be Empty: