I hereby authorize and request that copies of my prior medical records related to speech/physical/occupational/feeding therapies be delivered to Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLLC to establish or continue my healthcare treatment plan. This includes the complete assessment, most recent plan of treatment, progress summary, treatment notes and any other appropriately related documents or information.
I understand that for the purpose of continuing and coordinating my plan of treatment Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLLC. may be asked to release copies of my medical records, or such portions thereof as may be relevant to evaluations or treatment services, or reports or summaries thereof, to other healthcare providers, facilities (related school or daycare staff, case managers, school system, CDSA, etc.) and appropriately related professionals involved in my care.
My signature below indicates that I hereby authorize the release and disclosure of my protected health information to the following people on an as-needed basis as determined by Raleigh Therapy Services, Inc/Triangle Dysphagia & Feeding, PLLC. staff (choose all that apply):