Release of Info Form

Consent for Release of Information
Journey Pediatric Therapy

Fax document to: 208-441-2641 or email to: admin@journeypediatrics.com Phone: 208-627-8615
Client Information
Client Name*
Date of Birth*

MonthDayYear
Date
Phone Number*
I hereby authorize Journey Pediatric Therapy to (choose one):*

Exchange Information withRelease Information toObtain Information from
Records to be Released To/From
Organization Name/Person*
Organization/Person Phone Number*
Organization/Person Fax Number or Email *
Type of Records to be Released or Discussed*
I may revoke this authorization at any time by notifying Journey Pediatric Therapy in writing prior to expiration. Unless revoked earlier, this authorization will expire 1 year from the date created. I may inspect or copy any information to be used or disclosed under this authorization. I also understand that if the person or entity receiving this information is not a health care provider covered by federal privacy regulations, this information described above may be redisclosed and no longer protected by federal privacy laws or regulations. However, the recipient may be prohibited from disclosing my health information under other applicable state or federal laws and regulations.
Print Name (Parent/Guardian) Self if client is over 18 years old*
Relationship to Client*
Date*

MonthDayYear
Date
Signature (Parent/Guardian/Self)*

Clear
Should be Empty:

Consent for Release of Information