Harmony Autism Therapy- Release of Information Form

Release of Information

This form is secure and HIPAA Compliant
Patient Name *

First Name Last Name
Date of birth *

Month Day Year
mm/dd/yyyy Date Picker Icon
Phone *
E-mail *
Provider Information

With whom may we receive/send information to?
I hereby authorize the following person/agency to release/exchange my child's protected information with representatives of HARMONY AUTISM THERAPY:
Individual Provider *
(i.e., doctor, psychiatrist name)
Group Practice/Agency *
(i.e. practice, agency, school name)
Phone *
Fax *
I hereby authorize provider to exchange/release/obtain information *
Purpose of Release *
I give permission to exchange the following information (select ALL that apply) *
IF ANY, other information that I give permission to exchange
I understand that I may revoke this authorization at any time , except to the extent that action has already been taken in reliance upon it, by giving written notice to the Medical Records Department of the source facility. A revocation is not valid if (1) action was previously taken in reliance on this authorization, or (2) if this authorization was obtained as a condition for obtaining insurance coverage. I understand that I have the right to inspect the information to be disclosed upon the proper notification to and under conditions established by the source facility. I understand that my health care and payment for my health care will not be affected if I do not sign this form, depending on the plans requirements. I understand this authorization is voluntary. I understand that if the recipient of this information is not a health plan or provider, the released information may no longer be protected by federal privacy regulations and may be subject to re-disclosure. I understand that I am entitled to receive a copy of this completed authorization form upon request.
Signature *
Printed Name *

First Name Last Name
Relationship *
Patient's legal representative
Today's Date *

Month Day Year
Date Date Picker Icon
Should be Empty:

Release of Information

Provider Information