Authorization to Obtain or Release Info | Leap of Language

Leap Of Language Inc.

Speech & Language Therapy Services

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Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

stcin001@gmail.com

205-534-4330

Authorization to Obtain or Release Information

Client's First Name

Client's Last Name

Date of Birth

Address

For the reasons identified in this form, I hereby grant Leap of Language permission to communicate (exchange, obtain, or release) my medical information with the following person or agency:

Name of Person or Agency

Person/Agency Contact Information

Information to be Released:

Medical History

Therapy Evaluation

SLP

OT

PT

Other

Treatment Notes

SLP

OT

PT

Other

School Records (Evaluations, IEP, Academic Reports, etc.)

For the Purpose Of: (check all that apply)

Coordinating care with other professionals

Providing continuity of services

Updating therapeutic progress

Other

I grant permission to exchange information via written and mailed report, phone call, meeting, email, or fax

I understand that this authorization will remain valid until written revocation of this authorization is presented.

Signature of Client or Legal Representative

Today's Date

Relationship to Client

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Speech Therapy in Newark | Language Therapy in Newark | Pediatrics 94560