Authorization for Release of Information

904 6th Ave Ct NE Isanti, MN 55040
AUTHORIZATION FOR RELEASE OF INFORMATION
This form must be filled out COMPLETELY in order to be valid.

P (763)444-8700 F (763)434-0192
Patient Name*
Address*

Patient Address

Street Address Line 2

CityState

Zip
Date of Birth*

MonthDayYear
Date
Phone*
INFORMATION RELEASED*

TOFROM
Name of Facility*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone
Facility Fax
INFORMATION RELEASED*

TOFROM
Name of Facility: Therapy Associates, Inc.

904 6th Ave. Ct. NE Isanti, MN 55040

Facility Phone: (763) 444-8700
Therapist*
INFORMATION TO BE RELEASED
Choose from the options below*

Speech and/or Occupational Therapy ReportsMental Health (excludes psychotherapy notes)
Date(s)

MonthDayYear
Date
To

MonthDayYear
Date
**Mental Health Release needs to be separate from Speech/OT records.

If authorizing for Speech and/or Occupational AND Mental Health, 2 RELEASES MUST BE COMPLETED.

**Reports may indicate the following information: mental healthcare, communicable diseases, HIV or AIDS, and treatment of alcohol or drug abuse.**
Choose from the options below*

DO NOT RELEASE INFORMATION RELATING TO MENTAL HEALTH, COMMUNICABLE DISEASES, HIV OR AIDS, AND TREATMENT OF ALCOHOL OR DRUG ABUSE.Verbal Exchange (no copies)Other
INFORMATION IS RELEASED FOR THE PURPOSE OF:*

Transfer of CareCoordination of CareEducational ProgrammingOther
INFORMATION is RELEASED FOR THE PURPOSE OF:
- I understand that this authorization is effective for 1 year from the date of the signature unless otherwise specified below. Authorization is not valid if after 1 year from the date of signature.
- I understand that I have the right to revoke this authorization at any time by sending a written request to Therapy Associates. I understand that revoking this authorization does not apply to information that has already been released under this authorization.
- I understand that the protected health information Therapy Associates releases may be subjected to re-disclosure by the recipient and may not be protected by federal privacy laws.
- I understand Therapy Associates will not condition treatment, payment, enrollment or eligibility for benefits on whether I sign this authorization.
By signing below, I authorize Therapy Associates to use and disclose the protected health information described above to the entity/person listed above.
Print Name*
Relationship to Patient*
Patient/Parent/Legal Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR RELEASE OF INFORMATION