Occupational Therapy Communication Authorization Form

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Authorization for Communication

I, _________________________, hereby authorize [Practice Name] to:

Share Information With:

• Primary Care Physician: □ Yes □ No
• Other Healthcare Providers: □ Yes □ No
• School/Employer: □ Yes □ No
• Family Members (specify): _____________________
• Other (specify): _____________________

Approved Communication Methods:

• Phone calls: □ Yes □ No
  • Voicemail messages: □ Yes □ No
  • Detailed messages: □ Yes □ No
• Text messages: □ Yes □ No
• Email: □ Yes □ No
• Written correspondence: □ Yes □ No

Information to be Shared:

□ Assessment Results □ Treatment Plans □ Progress Reports □ Attendance Records □ Billing Information □ Other: _____________________

Duration

This authorization is valid for: □ One year from date of signature □ Duration of treatment □ Other: _____________________

Understanding and Rights

I understand that:

• I can revoke this authorization at any time in writing
• Treatment is not conditional upon signing this authorization
• Information shared may be re-disclosed by recipients
• I have the right to receive a copy of this authorization

Signature: _____________________ Date: _____________

Print Name: ____________________

Relationship to Patient (if applicable): ____________________