Authorization to Exchange, Obtain, or Release Information (ROI)

Authorization to Exchange, Obtain, or Release Information
Regarding (Client Name)

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please enter the person or facility that you would like us to be able to collaborate with by exchanging information regarding your child's care with Northwest Pediatic Therapy and associates. There are multiple spaces below if you have more than one person/facility to release information to. You must enter at least one person/facility to release information to.
Who do you want us to communicate with? -- (Name of Program/Person Authorized to Disclose/Receive/Exchange Information)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Who do you want us to communicate with? -- (Name of Program/Person Authorized to Disclose/Receive/Exchange Information)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Who do you want us to communicate with? -- (Name of Program/Person Authorized to Disclose/Receive/Exchange Information)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Who do you want us to communicate with? -- (Name of Program/Person Authorized to Disclose/Receive/Exchange Information)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax Number
Please enter a valid phone number.Format: (000) 000-0000.
Information to be Released

Other
For the Purpose Of: (check all that apply)

Other
Name of Parent/Guardian providing consent to release:

First NameLast Name
I hereby grant Northwest Pediatric Therapy and its affiliates (including, Neato Neuro LLC, Sprout Pediatric Therapy, and Northwest Pediatric Speech Therapy) permission to communicate with the aforementioned person/s and/or agency/ies.
Signature
Date signed

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Any other information or comments regarding this release (optional):
Should be Empty: