• 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

     

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  • 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:

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    • 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.
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