Authorization to Exchange, Obtain or Release Information Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

A PDF copy of this Form will be sent to your Email Address.

What is your Email Address? *

What is Client/Child's Name? *

What is Client/Child's Date of Birth *

YYYY

Enter Client/Child's Home Address *

Whats your relationship to Client/Child? *

I Grant iSpeak Therapy Services permission to communicate with the people or agencies listed below *

I Agree

Please enter the Recipient(s) who iSpeak Therapy Services can communicate information to:

Please enter the name, address, phone/fax. Examples: School/Physician/Insurance/Other Health Professionals (Please skip this section)

Information to Be Released: *

Medical History

Therapy Evaluation

Treatment Notes

School Records (Evaluations, IEP, academic reports, etc.)

Other:

Required

For the Purpose Of: (check all that apply) *

Coordinating care with other professionals

Providing continuity of services

Updating therapeutic progress

Other:

Required

I grant permission to exchange information via written and mailed report, phone call, meeting, email, or fax. *

I Agree

I understand that unless revoked, this authorization will remain valid until written revocation of this authorization is presented. *

I Understand

Parent/Legal Guardian Signature *

By typing and submitting my name below I am agreeing that all of the information above is correct. I also acknowledge that by typing and submitting my name below I am agreeing that it will be used as my legal binding signature.

Submit

Clear form

Never submit passwords through Google Forms.

This form was created inside of iSpeakTherapyServices. Report Abuse

Forms