7. Release of Information

Release of Information Authorization Form

If you would like us to review treatment plans from the previous ABA provider/ Therapy Group, Pediatrician, or School please complete the form below so that we may request and/or share applicable information.
Name of Patient*

First NameMiddle InitialsLast Name
Date of Birth:*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Full Name:
Phone Number:

Area CodePhone Number
I understand that this release is voluntary and applies to all programs and services operated under the auspices of Juniper Health & Wellness, LLC, I understand that my personally identifiable information (PHI) may be protected by the federal rules for privacy under the Family Educational Rights and
Privacy Act (FERPA), the Health Insurance Portability and Accountability Act (HIPAA), and/or applicable state or federal laws and regulations.

I understand that my PHI may be subject to re-disclosure by the recipient without the specific written consent of the person to whom it pertains, or as otherwise permitted.

I also understand that the recipient may not condition treatment, payment, enrollment, or eligibility on whether I sign this form, except for certain eligibility or enrollment determinations.

I understand that I may revoke this authorization at any time by notifying Sonya Ashley of Juniper Health & Wellness, LLC in writing but if I do it will not have any effect on any actions taken before the receipt of the revocation.
Organization or Individual Receiving and/or Communicating the Information
Name of organization or individual that we may collaborate with:*
Enter names of school, therapy organizations, or doctors that we may collaborate with. Only enter one provider per form. Additional forms maybe be provided for additional locations.
Organization Address:
Enter the address of the school, therapy organization, or doctor that we may collaborate with.
Organization Phone Number:*

Area CodePhone Number
I hereby authorize Juniper Health & Wellness, LLC to (mark all that apply):*

Release information toObtain information fromRelease and obtain information from
I hereby authorize Juniper Health & Wellness, LLC to exchange/release/obtain information in the following manner (Check one):*

Verbally onlyIn written formBoth verbal and written form
Description of Information to be exchanged/released/obtained (Mark all that may apply):*

MedicalPsychiatricEducational RecordsHistoryPsychological/SocialOther
This authorization is effective through the date indicated below unless otherwise revoked or terminated by the Patient or the patient's parent/guardian .
This authorization will expire on:

MonthDayYear
Date (Note: if a date is not noted, this authorization will expire 1 year from the date of signature.
Parent/Guardian Completing Form*

First NameLast Name
Parent / Guardian Signature*

Clear
DateTime
Should be Empty:

Release of Information Authorization Form