ITTS For Children
Individual and Team Therapy Services
COMMUNICATION RELEASE
Please complete all sections of this release form. If any sections are left blank, this form will be invalid and it will not be possible for your health information to be shared as requested.
Section 1: Client Name
Client Name
*
First Name
Last Name
Section 2: Health Information
I would like to give ITTS For Children permission to:
*
Disclose my child’s complete health record including, but not limited to: diagnoses, test results, reports, notes, treatment, and billing records for all conditions.
Disclose my child's complete health record except for the following information:
Please list any exceptions here:
I hereby grant ITTS For Children permission to contact the individuals/agencies listed below on behalf of the Client Name listed:
*
Signature of Client or Parent/Guardian if below 18
*
Parent/Guardian Name
First Name
Last Name
Email:
*
example@example.com
Date
*
-
Month
-
Day
Year
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Submit
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