Authorization to Release Information

Information and Records Template
Note: Use a new form for each provider. Please make additional copies, as needed.

I/We hereby give permission and consent to ARTISTIC LEGENDS ABA to release confidential information in my child's clinical record (e.g., behavioral assessments, behavioral data, etc to the following practitioner:
Name
Title
Company/School/Practice
(street)
(City)
(Zip)
Email
example@example.com
(PRINT)
(dd)
(yyyy)
Parent/Guardian #1 Name (PRINT)
Parent/Guardian #1 (Signature)

Clear
Parent/Guardian #2 Name (PRINT)
-0-14
ARTISTIC LEGENDS
Parent/Guardian #2 (Signature)
Should be Empty:

Information and Records Template