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: Name and contact information of Medical Professionals/Educational Staff/Therapists/etc: Name Contact Info Name Contact Info Name Contact Info Parent/Caregiver Signature Date As this child’s parent or guardian, I give my consent and permission for my child to receive medical and wellness services by Pure Pediatric Therapy therapists and staff to include evaluations, procedures and or treatments prescribed by my physician and my child’s therapist as is necessary in their judgment. Pure Pediatric Therapy has my permission to photograph and/or videotape my child to use in evaluation or treatment. Pure Pediatric Therapy has my permission to use my child’s photograph/video and description of such media publically to promote the clinic. I understand that the images/videos/description may be used in print publications, online publications, presentations, websites, and social media. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.