Release of Information from Another Entity to Children’s Therapy Services 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 the following entity to release to Children’s Therapy Services Early Intervention the information listed below. Entity:Please list requested information: All information released is for the expressed purpose of developing and integrating an effective plan of treatment for the child named above. I understand that this information is confidential and will only be viewed by members of my child’s Early Intervention team. I understand that I have the right to cancel this authorization at any time. Date MM slash DD slash YYYY
