RELEASE/EXCHANGE OF INFORMATION

By filling out and submitting the following form, I authorize Sound Beginnings Speech Therapy Services to release and/or exchange information regarding my child to the listed persons. Release of this information is for the purpose of providing speech therapy services which will meet the needs of my child. This may include information regarding therapy progress, related medical, therapeutic, or educational records, or insurance information (i.e. diagnostic or therapy codes). I understand that in order to protect the confidentiality of records, my agreement to obtain or release information is necessary. This consent will be in effect throughout the duration of my child's treatment, although I may withdraw my permission at any time by providing a statement in writing.

I allow the release of my child’s information to the following persons or agencies (include professional or agency name, address, & phone/fax #'s):

Professional or Agency Name 1

Phone of Name 1

(###)

###

####

Fax of Name 1

(###)

###

####

Address of Name 1

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Professional or Agency Name 2

Phone of Name 2

(###)

###

####

Fax of Name 2

(###)

###

####

Address of Name 2

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Professional or Agency Name 3

Phone of Name 3

(###)

###

####

Fax of Name 3

(###)

###

####

Address of Name 3

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Professional or Agency Name 4

Phone of Name 4

(###)

###

####

Fax of Name 4

(###)

###

####

Address of Name 4

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Child's Name

First Name

Last Name

Child's Date of Birth

YYYY

Parent/Legal Guardian's Name

First Name

Last Name

Today's Date

YYYY

Information limitations (optional)

OPTIONAL: This release of information or ability to obtain information is limited to the following: