AUTHORIZATION TO RELEASE/REQUEST RECORDS

AUTHORIZATION TO RELEASE/REQUEST RECORDS
Client Name:*
Client Date of Birth:*

MonthDayYear
Date
Client Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client Phone Number:
Please enter a valid phone number.
Client Email:
example@example.com
Is the client a minor?*

YesNo
Does the client have a disability that prevents them from being able to complete this form and be financially responsible?*

YesNo
If yes to either of the above, please list a Responsible Party:
Responsible Party relation to client:
Caregiver, Parent, Guardian, Power of Attorney, etc.
I authorize Moving Mountains Therapy Center, PLLC, to release and/or request records for the above-stated client for:

All past, present, and future recordsAll records during the time period listed below
Stated time period:
Past 6 months, January 2018-March 2020, etc.
I authorize that the following records may be released and/or requested:
Record/Reports

Speech Therapy Records/ReportsFeeding Specialist Records/ReportsOccupational Therapy Records/ReportsHealth and Physical Records/ReportsPhysical Therapy Records/ReportsIndividualized Family Service Plan (IFSP)Mental Health/Counseling/PsychologistIndividualized Education Plan (IEP)School Evaluation Records/ReportsDietician Records/ReportsOther
I authorize the records selected above may be released and/or requested from the following facilities.
Facility 1 Name:
Records may be

Released from Moving Mountains Therapy Center to the Facility 1Requested by Moving Mountains Therapy Center from the Facility 1
Facility 1 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility 1 Phone:
Please enter a valid phone number.
Facility 1 Fax:
Please enter a valid phone number.
Facility 2 Name:
Records may be

Released from Moving Mountains Therapy Center to the Facility 2Requested by Moving Mountains Therapy Center from the Facility 2
Facility 2 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility 2 Phone:
Please enter a valid phone number.
Facility 2 Fax:
Please enter a valid phone number.
Facility 3 Name:
Records may be

Released from Moving Mountains Therapy Center to the Facility 3Requested by Moving Mountains Therapy Center from the Facility 3
Facility 3 Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility 3 Phone:
Please enter a valid phone number.
Facility 3 Fax:
Please enter a valid phone number.
- I understand that by signing this authorization:
- I authorize the use or disclosure of my individually identifiable health information as described above for the development of the above stated patient’s treatment program.
- I have the right to withdraw permission for the release of the above stated patient’s information. If I sign this authorization to use or disclose information, I can revoke that authorization at any time. The revocation must be made in writing and will not affect information that has already been used or disclosed.
- I have the right to receive a copy of this authorization.
- I am signing this authorization voluntarily and treatment, payment, or my eligibility for benefits will not be affected if I do not sign this authorization.
- I further understand that a person to whom records and information are disclosed pursuant to this authorization may not further use or disclose the medical information unless another authorization is obtained from me or unless such disclosure is specifically required or permitted by law.
Signature of Client or Responsible Party*

Clear
Date*

MonthDayYear
Date
Should be Empty: