Signature_______________________________________________ Printed Name____________________________________________ Relationship to child_______________________________________ Metro Therapy Special Children’s Clinic, Inc. 7241 University AVE NE Fridley, MN Patient Release and Authorization I, (parent’s name) _________________________________________, authorize the use and/or disclosure of health information as set below for: (child’s name) _________________________________________. The following health information may be used and/or disclosed pursuant to this authorization: X Medical Records X Health Information X IEPs/ Plans of Care/ Evaluations I authorize Metro Therapy to receive/give health information regarding this child. I authorize the following person(s) or of person(s) to receive/give health information concerning this child:
Signature_______________________________________________ Printed Name____________________________________________ Relationship to child_______________________________________ Metro Therapy Special Children’s Clinic, Inc. 7241 University AVE NE Fridley, MN Patient Release and Authorization I, (parent’s name) _________________________________________, authorize the use and/or disclosure of health information as set below for: (child’s name) _________________________________________. The following health information may be used and/or disclosed pursuant to this authorization: X Medical Records X Health Information X IEPs/ Plans of Care/ Evaluations I authorize Metro Therapy to receive/give health information regarding this child. I authorize the following person(s) or of person(s) to receive/give health information concerning this child:
Insurnace-and-dev-history.docx