EXCHANGE OF INFORMATION LLC

EXCHANGE OF INFORMATION LLC

I hereby authorize Tiny Voice Therapy Services, LLC to exchange information with the individuals and/or organizations identified below for the purpose of coordinating care and developing, implementing, and/or updating a Speech/Language Therapy program for the above-named client.The types of information and providers authorized for exchange are indicated below.This authorization permits Tiny Voice Therapy Services, LLC to receive and/or disclose the authorized information with the individuals and/or organizations identified below. This authorization shall remain valid for the duration of the client’s services with Tiny Voice Therapy Services, LLC, unless revoked or otherwise modified in writing.
Child's Full Name

First NameLast Name
Child's Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Information to be released
Provider's Full Name

First NameLast Name
Provider's Email
Provider's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Signature of Client, Parent, or Guardian
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty: