Exchange of Information

Exchange of Information
Patient's Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
I authorize We Are Better Together, LLC therapists and staff to release/obtain information on behalf of my child the following provider:*
Provider's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
For the Purpose of: *
Ex. Speech Therapy Services, Occupational Therapy Services, Educational Planning etc
By signing this form, I understand that protected health information (PHI) will be shared in person, over the phone, or by fax. This form is good for one year from the date signed. I also understand that I can revoke consent at any time.
Parent or Guardian's Signature

Clear
Parent or Guardian's Printed Name*

First NameLast Name
Today's Date:*

MonthDayYear
Date
Should be Empty: