TherapyWorks Information Release Form

TherapyWorks Information Release Form

Which provider does your child see?

Select or enter value

Client Name*

Client Date of Birth*

Name of Parent/Guardian Signing*

I certify that I am the individual named above or that I have legal authority to sign on behalf of the individual named above. I acknowledge that by typing my name below, I am signing a legal document.

Signature Authorization*

Authorization for the Release of Information

Name of Agency/Physician/Organization*

Please select the information you approve for release.*

All available information

Medical reports

Educational reports

Other (please explain below)

Please explain other information authorized to be shared.

Information Release*

TherapyWorks Cincinnati, LLC is authorized and requested to release and/or receive the above information for the purpose of providing the appropriate services and continuity of care.

I do NOT give my consent for TherapyWorks Cincinnati, LLC to release or receive any information regarding my child.

Signature*

Send me a copy of my responses

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