Authorization for Release of Occupational Therapy Records

Patient Information

• Full Name: _________________________ Date of Birth: //___
• Address: ________________________________________________
• Phone: ______________________ Email: ______________________

Records to be Released From

Facility/Provider Name: ________________________________________ Address: ___________________________________________________ Phone: ______________________ Fax: __________________________

Records to be Released To

Facility/Provider Name: ________________________________________ Address: ___________________________________________________ Phone: ______________________ Fax: __________________________

Information to be Released (check all that apply)

□ Complete OT Records □ Initial Evaluation □ Progress Notes □ Treatment Plans □ Discharge Summary □ Billing Records □ Other (specify): ___________________________________________

Date Range

From: //___ To: //___

Purpose of Release

□ Continuing Care □ Insurance □ Legal □ Personal Use □ Other (specify): ___________________________________________

Authorization

I understand that:

1. This authorization is valid for 12 months unless otherwise specified
2. I may revoke this authorization at any time in writing
3. Once information is released, the facility cannot prevent its redisclosure
4. I have the right to receive a copy of this authorization
5. Treatment is not conditional upon signing this authorization

Signature: _________________________ Date: //___ Relationship to Patient (if not self): ___________________________

For Office Use Only

Request received by: _________________ Date: //___ Request processed by: _______________ Date: //___