Act_authorization to Release Confidential Information

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Atlanta Child Therapy, Inc. Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation 2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144 Atlantachildtherapy.org – 678.903.5506 Authorization to Release Confidential Information I hereby authorize the release of confidential information from: Atlanta Child Therapy, Inc. 2950 Cherokee Street, NW, Building 500 Kennesaw, Georgia 30144 I authorize the release of confidential information to: __________________________ _________________________ _________________________ Name if Individual Agency Phone Number I authorize the release of confidential information for the following time period: Indefinitely __________________ to ______________________ Start Date End Date The release of confidential information is too facilitate planning for: _____________________ _________________ __________ __________ Child’s Last Name First Middle Date of Birth You are hereby authorized to release the following specified information that may include any available third party records: Psychological Evaluations Medical Records Permanent Records/Transcripts Psychiatric Evaluations Vocational Guidance Reports Psychoeducational Evaluations Speech and Language Evaluations Audiological Reports Occupational Therapy Evaluations Staffing Reports Physical Therapy Evaluations Other ______________________________ I UNDERSTAND THAT THE GRANTING OF CONSENT FOR THE RELEASE OF RECORDS IS VOLUNTARY ON MY PART. ______________________________________________ __________________ Client/Guardian Signature Date ______________________________________________ Print Name

Transcript of Act_authorization to Release Confidential Information

  • Atlanta Child Therapy, Inc.

    Atlanta Child Therapy - a Georgia-based 501c3 non-profit educational therapy corporation

    2950 Cherokee Street, NW, Building 500, Kennesaw, Georgia 30144 Atlantachildtherapy.org 678.903.5506

    Authorization to Release Confidential Information

    I hereby authorize the release of confidential information from:

    Atlanta Child Therapy, Inc. 2950 Cherokee Street, NW, Building 500 Kennesaw, Georgia 30144

    I authorize the release of confidential information to:

    __________________________ _________________________ _________________________ Name if Individual Agency Phone Number

    I authorize the release of confidential information for the following time period:

    Indefinitely __________________ to ______________________ Start Date End Date The release of confidential information is too facilitate planning for:

    _____________________ _________________ __________ __________ Childs Last Name First Middle Date of Birth

    You are hereby authorized to release the following specified information that may include any available third party records:

    Psychological Evaluations Medical Records Permanent Records/Transcripts Psychiatric Evaluations Vocational Guidance Reports Psycho-educational Evaluations Speech and Language Evaluations Audiological Reports Occupational Therapy Evaluations Staffing Reports Physical Therapy Evaluations Other ______________________________ I UNDERSTAND THAT THE GRANTING OF CONSENT FOR THE RELEASE OF RECORDS IS VOLUNTARY ON MY PART.

    ______________________________________________ __________________ Client/Guardian Signature Date ______________________________________________ Print Name