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Release of Information from
Community 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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
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Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Request
MM slash DD slash YYYY
I hereby authorize Community 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
