Authorization for Release of Protected Health Information


Child's Name:(Required)
Child's Address:(Required)

I hereby authorize Coastal Speech Therapy, Inc. to release pertinent health information regarding my child to the following facilities. This includes medical records, clinic notes, school records and any pertinent information that will help in developing my child’s treatment program.

Facility 1 Address:(Required)
Facility 2 Address:

I understand that by signing this authorization:

  • I authorize the use or disclosure of my individually identifiable health information as described above for the development of my child’s treatment program.
  • I have the right to withdraw permission for the release of my child’s information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
  • I have the right to receive a copy of this authorization.
  • I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.
  • I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
Parent / Guardian Name:(Required)
Parent / Guardian Address:(Required)
Use your mouse or touch screen to sign.