Release of Information from Children’s Therapy Services to Another Entity Parent or Guardian First Name*Parent or Guardian Last Name*Phone Number*Email Address* Child's Name*Date of Birth* MM slash DD slash YYYY Home Address* Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Request MM slash DD slash YYYY I hereby authorize Children's Therapy Services Early Intervention to release the information indicated below to the following entity:Please check all information you would like to release: IFSP/IEP Evaluation Report Annual Review Medical/Developmental History Other Please specify "Other": All information released is for the expressed purpose of developing and integrating an effective plan of treatment for the above named child. I understand that this information is confidential and will only be viewed by professional individuals involved in my child’s care. I understand that I have the right to cancel this authorization at any time. Date MM slash DD slash YYYY
