Authorization for Request for Release of Records

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This form is a HIPAA compliant form from the child/family giving Montgomery Pediatric Physical Therapy Center, LLC (dba MOCO Movement Center) permission to disclose PHI for the purpose requested by the child or family.

By signing this document I permit Montgomery Pediatric Physical Therapy, LLC (dba MOCO Movement Center) to disclose health information (such as but not limited to exchange information regarding therapeutic services, POC) at MOCO for the purpose stated below. *

I grant permission

Required

Name of person requesting the information *

Relationship to patient *

Are you an authorized representative for the client? *

Child's Name *

Child's Date of Birth *

YYYY

Name of MOCO Provider *

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