Consent for Communication of Protected Health Information via Telehealth

This consent form authorizes the Zarlengo Foundation Learning Evaluation Center (LEC) to receive, transmit and communicate Protected Health Information (“PHI”) via electronic and other remote means, including sessions via video conferencing. 

Sign in to Google to save your progress. Learn more
Email *
Please type your Child's Name Below.
Next
Clear form
Never submit passwords through Google Forms.
This form was created inside of Havern School. Report Abuse