Authorization to Obtain or Release Info

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:

Medical History

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

Coordinating care with other professionals

Providing continuity of services

Updating therapeutic progress

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.

Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

205-534-4330

Authorization to Obtain or Release Information

Information to be Released:

Leap of Language Inc.

37171 Sycamore Street Apt. 633, Newark, CA 94560

stcin001@gmail.com

205-534-4330

Authorization to Obtain or Release Information

Information to be Released: