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 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

Other
For the purpose of:

Other
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)
Date

MonthDayYear
Date
Small Talk Pediatric Thearpy Meridian, Idaho 83646 www.smalltalkpediatrictherapy.com
Should be Empty: