Authorization to Disclose Medical Records

Authorization to Disclose Medical Records
All information submitted on this form is encrypted, transmited over a secure connection and stored on a HIPAA-compliant server.

NOTE: This form must be completed by the patient's parent or legal guardian
Patient's Name *

First Name Last Name
Date of Birth *

Month Day Year
Parent/Legal Guardian *

First Name Last Name
Completion of this form will serve as written permission for Sprout Therapy Services, LLC to communicate with the individuals you have listed below for the purposes you identify.

I authorize Sprout Therapy Services, LLC to send/disclose information to and receive Information from:

Purpose (select all that apply): *

I (or my dependent) have changed providers and want my records sent to the new provider. I want those I included above to communicate with Sprout Therapy Services in order to coordinate my (or my dependent's) services/care. This includes sharing evaluation findings, plan of care, and progress/response to therapy, techniques, and strategies.
Notes
I understand that:
- I am not required to sign this authorization to receive treatment.
- I am allowed to see/copy the health information that will be used or shared.
- I can revoke this authorization at any time by faxing or mailing Sprout Therapy Services. If I revoke access, I understand that any information that was shared before cannot be returned.
- The person or organization that receives my health information because of this authorization may have the right to share it with others without my permission.
Signature (use your mouse or touch pad) *
Print Name *

First Name Last Name
Should be Empty: