Authorization for Release of Speech Therapy Records

Patient Information

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

Records to be Released From

Practice/Provider Name: ____________________________________ Address: ________________________________________________ Phone: _________________ Fax: ____________________________

Records to be Released To

Practice/Provider Name: ____________________________________ Address: ________________________________________________ Phone: _________________ Fax: ____________________________

Information to be Released (check all that apply)

□ Complete Speech Therapy Record □ Initial Evaluation □ Progress Notes □ Discharge Summary □ Treatment Plans □ Assessment Results □ Video/Audio Recordings □ 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 releasing facility cannot prevent its redisclosure
4. Treatment is not conditioned upon signing this authorization

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

For Office Use Only

Request received: //___ Records released: //___ Staff initials: _____