Authorization for Release of Information Authorization for Release of Information Authorization for Release of Information Please complete one form for each individual with which you are providing an authorization for release of information. Client Information Client / Child's Name * Client / Child's Date of Birth * Address * City, State, Zip * Phone * Health Information to be Released To: Agency / Person * Address * City, State, Zip * Phone Number * Fax Number * The information that will be used or shared will include * Speech and language evaluation results Treatment records or summaries OtherOther Check all that apply I understand that I am allowed to see or copy the health information that will be used or shared. I can take back this authorization at any time in writing by mailing my request to: Bailey Levis SF Speech and Fluency Center PO Box 318003 San Francisco, CA 94131 Any information that was used or shared before I took back this authorization cannot be returned. The person or organization that gets my health information because of this authorization, may have the right to share it with others. This authorization is valid during the course of treatment and up to one year after the end of treatment. Signature Required Person Signing this form * Relationship to client * Signature * Clear Enter your email to receive a copy of this authorization Entering your email does not add you to any mailing lists. Your information is never shared. Confirm Enter your email to receive a copy of this authorization Submit If you are human, leave this field blank.