Cobb Speech & Language Services, LLC
info@cobbspeechandlanguage.com
Medical Release of Confidential Information
Patient Name:
First Name
Last Name
DOB:
-
Month
-
Day
Year
Date
Street Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I understand that this release is voluntary and applies to all programs and services operated under the auspices of Cobb Speech & Language Services, LLC. I understand that my personal identifiable information (PII) may be protected by the federal rules for privacy under the Family Educational Rights and Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPAA), and/or other applicable state of federal laws and regulations. I understand that my PII may be subject to re-disclosure by the recipient without specific written consent of the person to whom it pertains, or as otherwise permitted. I also understand that the recipient may not condition treatment, payment, enrollment or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations. I understand that I may revoke this authorization at any time by notifying Cobb Speech & Language Services, LLC in writing, but if I do, it will not have any effect on the actions taken before the receipt of the revocation. This release once signed will remain in effect unless otherwise revoked.
I hereby authorize Cobb Speech & Language Services, LLC (check all that apply)
Exchange information with
Release information to
Obtain information from
The following Organization/ Physician Name/Other Individuals in regard to the above-named patient: Name of organization/ Individual:
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone:
Format: (000) 000-0000.
I hereby authorize this information to be exchanged in the following manner (check all that apply)
Verbal Only
Written Only
Verbal and Written
Description of Information to be exchanged:
Education Records
Evaluation/ Assessment/ Eligibility
Clinical (ST/ PT/ OT/ Behavioral)
This information is to be used for diagnostic, treatment planning, and continuity of care purposes only.
I do not give my consent
Signature of Client or Legal Representative
Relationship to Client
Date
-
Month
-
Day
Year
Date
Preview PDF
Submit
Should be Empty: