I, _______________________________________________ the legal parent/guardian of the patient named below, give Communication Made Easy, Inc., permission to obtain from or give to the above-named agency or person, pertinent social, medical, or other information as listed below. I understand that this information is confidential and will only be used for the benefit of this patient. I understand that this information may be subject to re-release by the recipient without the knowledge or consent of CME Inc., and that CME Inc., is in no way responsible for this action. I further understand that this consent form is considered valid for 1 year or for the duration of this patient’s enrollment, whichever is shortest, and that I may revoke this release at any time by requesting this in writing and submitting it to this office or by requesting this form and signing below.*Notice: CME Inc., may not condition services upon signing this form unless the services are being provided for a third party.