MBR i-Go Liability Waiver / Rental Agreement

Child's Name *

First Name Last Name

Date of Birth *

Date Picker Icon

Clinician *

This form, when completed and signed by the parent/guardian, authorizes the release of protected health information from your child’s clinical/medical record to the person and/or institutions you designate.

neuroBridge believes strongly in a team approach as the most effective treatment, and to achieve the greatest potential for a child’s success.
Therefore, neuroBridge and its healthcare professionals are authorized to release or exchange information with the following individuals in order to develop assessment/treatment plan or coordinate treatment and care:

*

A copy of the Psychological Assessment and Progress Report to the child’s Pediatrician Communicate with child’s Pediatrician regarding medication recommendations Communicate with child’s teacher regarding effective classroom recommendations Communicate with nB therapists who are serving the child for OT and/or SLP Communicate with school administration regarding scheduling of services Communicate testing results and recommendations to the school academic advisor Other information

Please add any additional person or persons not listed above with whom you wish for neuroBridge’s clinical psychologist to exchange information with/obtain from/release to: *

This authorization shall remain in effect throughout the period of involvement with clinical psychology.

You have the right to revoke this authorization, in writing, at any time by sending such written notification to our office address.
However, your revocation will not be effective to the extent that we have taken action in reliance on the authorization.
I understand that NeuroBridge LLC generally may not condition services upon my signing an authorization unless the services are provided to me for the purpose of creating health information for a third party.

I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the information recipient and no longer protected by the HIPPA Privacy Rule. I understand all of the aforementioned, and with informed consent and of my own free will, authorize this disclosure of protected health information.

Signature of Parent or Guardian for Minor Child *

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Photocopy of this release shall be considered as effective as the original when presented.

Release of Psychotherapy Notes: I am informed that HIPPA affords special protection of psychotherapy notes in an effort to preserve confidentiality in psychotherapy. I understand HIPPA forbids payers from requiring disclosure of these as a condition for payment. I hereby request release/disclosure of psychotherapy notes associated with mycare from/to Dr. Berry-Sawyer for (reasons) *

Signature of Parent or Guardian for Minor Child *

Clear

Authorization for the Release of Information-Clinical Psychology