Release of Information

Release of Information
Client Name*

First NameLast Name
Client Date of Birth*

MonthDayYear
I authorize Tosa Pediatrics to send and receive the following information:
- Medical history and evaluation(s)
- Mental health evaluations
- Developmental and/or social history
- Progress notes, and treatment or closing summary
- Educational Records
- Other: ____________________________________
With the following organization or person:
Name (i.e. health facility, physician, school, teacher)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
example@example.com
Signature*

Clear
Date*

MonthDayYear
Date
Printed Name*

First NameLast Name
Relationship to Client*
Should be Empty: