TLC Authorization for Release of Information

Authorization for Release of Information
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Client’s Name
DOB
I,
(client or legal guardian), herebyauthorizes Therapy and Learning Center of GA to

SEND and/orRECEIVE
Information

TO and/orFROM
Name of Person or Facility
Address
Phone
Information

Educational Evaluation ResultsOccupational/Physical Therapy ReportsBehavior Intervention PlanMedical RecordsSchool RecordsEntire RecordPsychological ReportsSpeech and Language Evaluation/Progress NotesAudiological ReportPsychological Testing ResultsOther (specify)
The above information will be used for the following purposes

Planning Treatment of ProgramDetermining Eligibility for Benefits or ProgramUpdating FilesOther (specify)
1. I understand that authorization is voluntary and I may revoke consent at any time by providing written notice.

2. Authorization is valid for the length of time that the above named patient is under the care of Milton Speech Pathology.

3. I have been informed what information will be given, its purposes and who will receive the information.

4. I understand that I have a right to receive a signed copy of this authorization. I understand that I have the right to refuse to sign this authorization.
Signature

Clear
Relationship to Client
Print Client’s Name
Date

MonthDayYear
Date
Should be Empty: