Gwen’s Speech Therapy        

“Communication is the Key”

        

Gwen Fowler-Berken, MS, CCC-SLP                P:828-371-3940

310 Terrell Road, Franklin, NC 28734                 F:828-369-7497

GA Lic #SLP008575        gwen@gwenspeech.com

NC Lic #8653        www.gwenspeech.com

AUTHORIZATION FOR RELEASE OF RECORDS AND COMMUNICATION

Client’s Full Name:  _____________________________

Client’s Date of Birth: ___________________

I, ___________________________, authorize and request the disclosure of the following information:

Information to be utilized by Gwen Fowler-Berken, MS, CCC-SLP for the following purpose(s):

Additional persons authorized to receive client’s medical and allied services information include the following:

_________________________________________      _________________________________________

_________________________________________      _________________________________________

_________________________________________      _________________________________________

_________________________________________      _________________________________________

I understand that I have the right to revoke this authorization at any time through electronic messaging (email) or in a formal letter.

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Signature of Client/Parent/POA or Legally Authorized Representative  

______________________________                                        ___________________

Relationship to Client                                                        Date