Authorization of Release

Telephone: (919) 359-1323
Price range: $$

Authorization of Release/Receipt of Patient Information

Patient Name:(Required)

Date of Birth:(Required)

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.)

Authorizations

This request shall be valid for duration of treatment, unless previously revoked or otherwise indicated (specify number of days or months):(Required)

Reason For Release:(Required)

Other information:

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.

Signature(Required)

Date(Required)

1014 Adams Point Dr ~ Garner NC 27529 Phone (919) 359-1323 ~ Fax (919) 827-8754 www.nowweretalkingpt.com