Two Way ROI: Release of Information
Allowing for Greater Collaboration and Continuity of Care between Providers
This form provides Clarity Psychological Testing with written permission to communicate with the individuals listed below and those individuals to communicate with us regarding you or your child's treatment.
I consent
I do not consent
Signature
Please list the important people in you or your child's support team that you'd like us to collaborate with as we do the evaluation.
(teachers, psychiatrists, pediatricians, speech therapists, school counselors, therapists, etc.)
Provider 1 Name & email address
Information to be released from Provider 1
all records
clinical notes
x-rays
diagnostic testing results
treatment plan
Provider 2 Name & email
Information to be released from Provider 2
all records can be released
clinical notes
x-rays
diagnostic testing results
treatment plan
Provider 3 Name & email
Information to be released for Provider 3
all records
clinical notes
x-rays
diagnostic testing results
treatment plan
This release will be valid for up to one year post testing unless otherwise revoked.
I consent
I do not consent
Signature
-
Month
-
Day
Year
Date
Please Type your Full Name
Full Name
Continue
Continue
Should be Empty: