AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION
PHONE: 651-455-0561 | FAX: 651-457-4401
Client's Name:
*
First Name
Last Name
Client's Date of Birth:
*
-
Month
-
Day
Year
Date
Parent's Name:
*
First Name
Last Name
I request/authorize Therapy OPS staff to speak with and release/obtain the specific information identified below to:
Name:
Name of Individual/Clinic
Fax:
Fax Number
Phone:
Phone Number
Name:
Name of Individual/Clinic
Fax:
Fax Number
Phone:
Phone Number
Name:
Name of Individual/Clinic
Fax:
Fax Number
Phone:
Phone Number
This request and authorization applies to:
*
Health Records
Psychological Reports
Psychiatric Reports
Special Education Records
Initial Evaluations/Progress Reports
General Observations
Other/All Requested Documents
Parent/Caregiver Name:
*
First Name
Last Name
Signature
*
Today's Date:
*
-
Month
-
Day
Year
Date
THIS AUTHORIZATION EXPIRES ONE YEAR AFTER IT IS SIGNED. IT CAN BE STOPPED ANY TIME BY SENDING A WRITTEN REQUEST.
Therapy OPS
2925 Buckley Way, Inver Grove Heights, MN 55076 1312 S Frontage Rd, Hastings, MN 55033
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