Authorization for Release of Information
Client’s Name
DOB
I,(client or legal guardian)
hereby authorizes Mosaic Autism Services to
SEND and/or
RECEIVE information
TO and/or
FROM: Name of Person or Facility:
FROM: Name of Person or Facility
Address
Phone
Format: (000) 000-0000.
notes
Educational Evaluation Results
Occupational/Physical Therapy Reports
Behavior Intervention Plan
Medical Records
School Records
Entire Record
Psychological Reports
Speech and Language Evaluation/Progress
Audiological Report
Psychological Testing Results
Other (specify)
The above information will be used for the following purposes
Planning Treatment of Program
Determining Eligibility for Benefits or Program
Updating Files
Other (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 Mosaic Autism Services. 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 of Parent or Legal Guardian
Print Client’s Name
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: