Authorization for Release of Information
Please complete for any additional persons Behaven Kids is authorized to speak with
Client Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Date of Birth
-
Month
-
Day
Year
Date
I, hereby, as the parent or guardian of a child under the age of 18 years of age, or , I, as an eligible adult (18 years of age or older), do request and authorize: Behaven Kids to receive and provide the information below:
Official permanent record (parent's name, child's name, birth date, progress notes, data, standardized test scores, attendance data)
Results of psychological assessments and/or consultations
Medical records
Other Data
If other data was marked, please explain:
Institution or person receiving/providing information:
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
-
Area Code
Phone Number
Purpose for which the information is to be released:
This authorization shall be deemed to permit the continuing release of the designated information from the date signed through the following date, or until such time that this authorization shall have been revoked by me in writing:
-
Month
-
Day
Year
Date
I refuse to release information to providers for coordination of care (please initial if applicable)
Name of Guardian:
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Electronic Signature
Phone Number
-
Area Code
Phone Number
Submit
Should be Empty: