Authorization for Release of Confidential Information
Email address *
Client Name *
Your answer
Date of Birth *
MM
/
DD
/
YYYY
Name of Agency, School, or Practitioner: *
Your answer
Authorization *
I authorize the above named agency, school or practitioner to provide the following information regarding to Kids In Sync:
Required
For the purpose of: *
Your answer
I do / do not authorize Kids in Sync to provide the following information regarding my child to the above named agency, school or practitioner: *
Required
I do / do not authorize Kids in Sync to provide the below information regarding my child to the above named agency, school or practitioner: *
Required
Information specified: *
Required
For the following period of time: *
(If treatment period is unspecified, only records from the past 6 months will be released)
Your answer
This consent is valid until: *
MM
/
DD
/
YYYY
Understand that I may revoke this consent at any time by giving a written notice to Kids in Sync, and that I have the right to inspect and copy the information disclosed by him. It has been explained to me that if I refuse to consent to release of information services may be delayed or denied.
Signature of Client *
Your answer
Signature of Responsibility Party *
(Must sign if client is under 18 years of age; enter "N/A" if not applicable)
Your answer
Signature of Witness *
Your answer
A copy of your responses will be emailed to the address you provided.
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