• Release of Protected Health Information



    Client Name: * * Client DOB: *  
    Client's SS#:       

    I hereby authorize Early Bird Developmental Services, LLC and the following agencies   *  
    to share information from the health records of the above named client for evaluation and or treatment or for coordination of care.

    Documents to share might include any or all of the following:
    Social or Developmental History
    Occupational, Physical, Speech-Language or Feeding evaluations
    Developmental/Multi-Disciplinary Evaluations
    Individualized Family Service Plans
    Treatment Plans
    Progress Notes/Visit Notes
    Other:      
    Other:       

    I request the following limitations:      

    I understand that this authorization is valid for this course of care. I also understand that I can revoke this authorization at any time with notice to Early Bird office.
           

  • PRINTED NAME: *   *   

  •  (Relationship to Child):    *

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  • Providing Functional Developmental Intervention in the Natural Environment
    www.earlybirdonline.com Phone: (704) 846-0262 Fax: (704) 846-2958 

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