Common use of Authorization for Release of Information Clause in Contracts

Authorization for Release of Information. My child is a client of Pure Pediatric Therapy, Inc., and I authorize the release of information and relative documentation regarding my child’s participation in therapy. I understand I will be informed of the content of any conversations and release of medical information that is exchanged. Child’s Name Date of Birth I authorize the release of this information to the following professionals: Pediatrician/Physician: Additional Professionals: Parent/Caregiver Signature Date Therapist Name Date Patient’s Full Name: I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA) I have certain rights to privacy regarding my protected health information. I understand this information will be used to: