Release of Information - Request Form

Release of Information - Request Form

Thank you for continuing to use Tri-County Therapy for therapy services! To streamline our process, please complete the following form so that your request can filter directly to our Records Department.
Child's Legal Full Name:

Legal First NameLegal Last Name
Child's Date of Birth:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Parent/Guardian's Name:

Legal First NameLegal Last Name
Relationship to child:
Email Address:
example@example.com
Phone Number:

Area CodePhone Number
I authorize Tri-County Therapy to receive and/or send information from/to the following physicians or facilities as listed below:
1. Name of person/facility authorized to receive/send records or health information:
1. Email Address / Phone Number / Fax Number
For the person/facility receiving records or health information
2. Name of person/facility authorized to receive/send records or health information:
2. Email Address / Phone Number / Fax Number
For the person/facility receiving records or health information
3. Name of person/facility authorized to receive/send records or health information:
3. Email Address / Phone Number / Fax Number
For the person/facility receiving records or health information
Information received may include the following (check all that apply):
Other records to release/send:
In addition to therapy documentation, I also consent for my child's therapy progress to be discussed between therapy providers via email or telephone. Example: Your child receives therapy within the school system and with Tri-County Therapy, and you allow the providers to discuss your child's services and progress.
If yes, please list approved providers:
Date Requested:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Our office will complete this request within 2 business days. Thank you!
Should be Empty: