Release of Protected Health Information
Client Name: First Name* Last Name* Client DOB: Client DOB* Client's SS#: Optional I hereby authorize Early Bird Developmental Services, LLC and the following agencies With whom can we share your info?* 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 HistoryOccupational, Physical, Speech-Language or Feeding evaluationsDevelopmental/Multi-Disciplinary EvaluationsIndividualized Family Service PlansTreatment PlansProgress Notes/Visit NotesOther: Other Other: Other I request the following limitations: 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: First Name* Last Name*
(Relationship to Child): blanks*
Providing Functional Developmental Intervention in the Natural Environmentwww.earlybirdonline.com Phone: (704) 846-0262 Fax: (704) 846-2958