2020 Release of Information

Release of Information
Please enter the Access Code provided to fill out the form.*

Child's Name*

First NameLast Name
Date*

MonthDayYear
Date
Caregiver completing form*

First NameLast Name
Caregiver's relationship to child*
Email*
example@example.com
I hereby give permission for Therapy West, Inc. to exchange medical, educational, psychological and/or developmental information for the purposes of treatment, payment, and/or health care operations regarding my child with the following:
Please check all that apply and supply contact information for each:*

NoneOccupational TherapistPhysical TherapistSpeech and Language TherapistMedical DoctorBehavioristPsychologistOther
Please provide contact information below (name, phone number and discipline) for any specialists checked above.
I hereby authorize release of Therapy West, Inc. reports and documents relevant to the therapeutic and professional services of my child with the above-mentioned parties.
Signature*

Clear
Date*

MonthDayYear
Date
You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and delivered to the address at the bottom of this form. This may be delivered in person or by mail but it will only be effective when we actually receive it. Your cancellation will not be effective to the extent that we or others have acted in reliance upon this consent. Our Privacy Policy provides more detailed information about the usage and disclosure of your protected health information. You have the right to review our Privacy Policy before you sign this consent.
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