ocvt.info - AP Collab Form

PATIENT CARE AND COLLABORATION
PATIENT NAME:
DATE OF BIRTH:

MonthDayYear
Date
By signing below, I consent to the above listed providers receiving updates and reports from OCVT for collaboration on my care, including calls, record sharing, and school observations as applicable.
Full Name of PCP/Pediatrician:
Clinic/Location:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Check here if this professional referred you:
Vision/Eye Care Provider:
Clinic/Location:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Check here if this professional referred you:
Teacher or School Contact:
Clinic/Location:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Check here if this professional referred you:
Therapists (OT/PT/SLP):
Clinic/Location:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Check here if this professional referred you:
Psychologist/Psychiatrist:
Clinic/Location:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Check here if this professional referred you:
Neurologist or Other Provider:
Clinic/Location:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
Fax:
Check here if this professional referred you:
My signature below authorizes this clinic to share any of the patient’s medical records via phone or electronically, and to schedule school observations as the provider deems necessary. I understand that I may revoke this authorization at any time except for actions already taken based upon it. I understand that to revoke this authorization, I must submit a written revocation to the Patient Services Team via fax, mail, or in-person. I understand that this release does not expire unless or until a written revocation is received. I understand I may request a copy of this document at any time.
Signature of Patient or Parent/Guardian:
Date:

MonthDayYear
Date
Should be Empty:

PATIENT CARE AND COLLABORATION