Release of Information Form

HOUSE OF SPEECH

Authorization for Release of Health Information


Client’s Name: ______________________          Date of Birth: ________________

Dates of Service: From ________ (Month/Day/Year) to ________ (Month/Day/Year)

I hereby authorize disclosure of protected health information as follows:

Organization Sending Information:        Person/Facility Receiving Information:

House of Speech                                         Name: _____________________________

1049 32nd Street South                              Address: ___________________________

Birmingham, AL                                            ___________________________________ 

35205                                                            Phone: ____________________________

 

Types of Records to be released (please circle):

  • Speech/Language Evaluation(s)
  • Speech/Language Treatment Plans
  • Speech/Language Progress Reports
  • Case History
  • Other ________________________

By signing this release I acknowledge:

1. This information about the client is protected under federal law

2. I may refuse to sign the authorization.

3. I have the right to revoke this authorization in writing.

4. I recognize that the protected health information used or disclosed pursuant to this authorization may be subject to re-disclosure by the recipient of this disclosure and may no longer be protected under federal law.

5. Treatment or payment will not be based on my signing this authorization

6. I will receive a copy of this authorization if I request it.

 

________________________________               ___________________________

Signature of Client                                                      Date

(Or Guardian if client is a minor)

________________________________    

Relationship of Signatory to Client

________________________________            ____________________________

 Signature of Witness                                               Date