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Authorization of Release

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Authorization of Release/Receipt of Patient Information
I hereby authorize “Now We’re Talking” Pediatric Therapy, Inc to release and receive information in my patient record to: (i.e; CDSA, Pediatrician, Specialists, additional caregivers etc.)
I understand that by signing this form, that I hereby agree and authorize to the release of patient information to the above named person or organization. I have the right to revoke this authorization, in writing, at any time by sending such written notification to “Now We’re Talking” Pediatric Therapy, Inc office address. However, I understand that my revocation will not be effective to the extent that action based on this consent has been taken.
1014 Adams Point Dr ~ Garner NC 27529 Phone (919) 359-1323 ~ Fax (919) 827-8754

  • National Board for Certification in Occupational Therapy
  • American Speech-Language Hearing Association
  • American Physical Therapy Association
  • North Carolina Board of Examiners for Speech-Language Pathologists and Audiologists