Release of Information

Pediatric Speech Therapy Services

MEDICAL RECORDS RELEASE FORM AUTHORIZATION TO USE OR DISCLOSE PROTECTED HEALTH INFORMATION

(Parent/Guardian)*

(City, State)*

(Client/Child's Name)*

I hereby authorize Communication Dynamics Pediatric Therapy, LLC to use, disclose and/or discuss the following protected health information listed below from my medical records. I understand the information used or disclosed pursuant to this authorization could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting confidentiality.

Persons or entities with whom Communication Dynamics, LLC may disclose/discuss your Protected Health Information: (Releasees- i.e. Doctors, Dentists, Therapists, Schools/Teachers, etc

Communication Dynamics Pediatric Therapy, LLC is authorized to disclose/discuss the following information, including but not limited to: medical records; treatment records (progress notes, daily session notes); speech, language, academic, and/or swallowing test results; and evaluations/therapy progress as it relates to therapy/ treatment and evaluations at Communication Dynamics.

This information is being used or shared for medical, insurance, legal, and/or educational purposes.

I understand that I may revoke this authorization at any time by requesting such of Communication Dynamics Pediatric Therapy, LLC in writing, unless action has already been taken in reliance upon it, or during a contestability period under applicable law.

Name/Title of Entity or Business *

Address of Entity or Business (if full address isn't known, list City/State)*

Child's Date of Birth*

Date

Phone Number/Fax Number of Entity*

Parent/Guarantor Signature*

Date*

Date

Parent/Guarantor Name (Printed)*

Client Name (Printed)*

1385 Oglethorpe Street Macon, Georgia 31201-1511 478-746-1037 www.commdynamics.com