"*" indicates required fields

Authorization to Release Information

Use this form if you want Pediatric Connections to communicate information to your child’s school or other health care professionals (excluding your doctor who writes the script for services), social workers, etc. One authorization per person/agency. Please list anyone who may bring your child to therapy so that we can communicate OT sessions with them.
Client Name*
MM slash DD slash YYYY

I hereby authorize Pediatric Connections OT to use or disclose, request, and/or exchange my protected health information to the person/agency (allowing information exchange with anyone representing that agency) as indicated below.

Address*
Information to be released/exchanged*
Check all that apply:

Terms

This release will last for 12 months from date of signature or upon discharge of OT services.

Purpose

Pediatric Connections will exchange/release information for purposes of evaluation, treatment, case coordination, caregiver training, and follow-up care and for payment via phone, fax, and/or email.

I have read the above and authorize the request or disclosure of Protected Heath Information. I understand I may revoke this right at any time by providing verbal or written notice to Pediatric Connections except to the extent that action has been taken in reliance and on the authorization or as otherwise stated in Pediatric Connections' Notice of Privacy Practices.

Printed Client/Legal Guardian Name*
Clear Signature
MM slash DD slash YYYY
Address*