Small Talk Authorization to Release and/or Exchange Confidential Information

Small Talk Authorization to Release and/or Exchange Confidential Information
AUTHORIZATION TO RELEASE and/or EXCHANGE CONFIDENTIAL INFORMATION

authorize Small Talk Pediatric Therapy to:
I (parent name) authorize Small Talk Pediatric Therapy to *
authorize Small Talk Pediatric Therapy to*

release toobtain fromexchange with
Release info to:
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Pertaining to my child name*
DOB*
The following information that you are authorizing to share*

Treatment summary /progress notesHistory / IntakeDiagnosisSchool related information (i.e IEP, 504, etc)Outpatient therapy evaluation, progress notes, daily notesMedical informationOther
For the purpose of:*

evaluation/assessment and/or coordinating treatment effortscontinuation of careOther
This consent will automatically expire one (1) year after the date of my signature as it appears below.I understand I have the right to refuse to sign this form, and that I may revoke my consent at any time (except to the extent that the information has already been released)*

Clear
Date*

MonthDayYear
Date
Small Talk Pediatric Thearpy Meridian, Idaho 83646 www.smalltalkpediatrictherapy.com
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