Authorization for Release/Exchange of Information

Collaboration is a vital part of caring for our clients. Please complete this form and return to your clinician if you would like us to communicate with other professionals working with your child.

This is to give permission to release and/or exchange confidential information by phone, fax, email or mail regarding:

Client Name

First Last

This information includes any speech and language evaluation results, recommendations, and/or clinical information regarding this individual. This information is to be exchanged between the Center for Speech and Language Disorders dba CHAT and:

School/Office/Organization’s Name

Contact’s Name

First Last

Contact Title/Role

Address

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Please check if the following applies:

I authorize CHAT to obtain information regarding my child from the other named entity, but do not authorize CHAT to release information about my child at this time.

Name

First Last

Signature

Date