Authorization to Exchange, Obtain or Release Information

Authorization to Exchange, Obtain or Release Information
Client's Name

First NameLast Name
Client Birthdate

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I First Name Last Name (legal guardian) hereby grant, Communication Cottage Therapy LLC, permission to communicate with the following individuals/organizations, for the purpose of sending therapy updates and coordinating care.

Please include the facility name and people Communication Cottage Therapy is allowed to speak with regarding your child’s care as well as their contact information if applicable/known.
Payor/Insurance
Name of Primary Insurance Company
Name of Secondary Insurance Company (if applicable)
Doctor
Name of Doctor
Practice Location
Specialists
Please List (name, specialist type, and practice information for ALL specialists) example of specialists - OT, SLP, PT, ENT, ABA, GI, Neurology, etc
Daycare
Facility Name:
Address:
Teacher's Name(s):
Early Intervention
Company Name:
Early Interventionist/Service Coordinator
Name(s)
Early Interventionist Phone Number
Early Interventionist Email
School
Name of School:
Names + Contact Information (phone + email) of ALL providers (teacher, related services - OT/PT/Psych)
Caregivers/Other
If there are any other adults in the care of your child that are not your child's legal guardian that you wish to have information shared with to support them in better understanding ways to support your child - please list their names + Role in your child's life + contact information below (phone/email)
Additional Contacts (if applicable)
Information to be released
I grant Permission to exchange information via email, fax, meeting, phone call.
I understand that unless revoked, this authorization will remain valid unless written revocation of this authorization is present
Legal Guardian/Caregiver's Name

First NameLast Name
Date of Form Completion

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Authorization to Exchange, Obtain or Release Information

Payor/Insurance

Doctor

Specialists

Daycare

Early Intervention

School

Caregivers/Other