Authorization to Release Medical Records & Information Consent Form

Authorization to Release Medical Records & Information Consent Form
Submission ID
Please provide contact information for any clinicians, insurance contacts, therapy providers, school personnel or other individuals your ABA consultant, Speech-Language Pathologist or Occupational Therapist may share your child’s therapy progress with. Maintaining communication with physicians and other care providers can help create consistency of care for your child.

EAS personnel are required to maintain confidentiality regarding your child’s identity. Client files will be faxed to the primary care physician’s office to reduce risks associated with electronic communication.

Participation in consent is voluntary. You may revoke this authorization in writing at any time except to the extent that action has been taken in reliance upon the authorization. The authorization will expire six (6) months from the date of my signature, unless you revoke the authorization prior to that time. If there are any questions concerning consent to communication or confidentiality, please contact your assigned EAS BCBA or clinician.
Client Name

First NameLast Name
Client Date of Birth

MonthDayYear
Date
Authorized Contacts
Please check all of the provider types your child comes in contact with. (This may be required by your insurance for approval.)*

DoctorNeurologistTherapistSchool/TeacherDaycareCase WorkerOther
Please enter the contact information for each authorized contact. Please click "SAVE" after each submission.
Authorized Doctor(s)*
Authorized Neurologist(s)*
Authorized Therapist(s)*
Authorized School/Teacher(s)*
Authorized Daycare(s)*
Authorized Caseworker(s)*
Other Authorized Contacts*
YOUR SIGNATURE BELOW INDICATES THAT YOU HAVE READ AND COMPLETED EARLY AUTISM SERVICES LLC’S AUTHORIZATION TO RELEASE MEDICAL RECORDS/INFORMATION AND THAT YOU AGREE THAT YOUR CHILD’S THERAPY PROGRESS SHOULD BE SHARED WITH THE CONTACTS LISTED ON THIS FORM*

I have read and understand the above consent form. I AGREE that my child’s therapy progress should be shared with those contacts listed on this form.I do NOT consent to any individual at EAS sharing my child’s treatment documents.
Parent/Guardian Name*

First NameLast Name
Signature*

Clear
Date*

MonthDayYear
Date
Please select your location.*
Should be Empty:

Authorization to Release Medical Records & Information Consent Form

Authorized Contacts