Speak Up Speech Oregon | Ashley Johnson |Consent to Release Medical Information

Child's Name*

I authorize Speak Up Speech Therapy to:*

Send
Receive

The following information:

Medical history and evaluation(s)
Mental health evaluations
Developmental and/or social history
Educations records
Progress notes and treatment or closing summary
Other

To / From:

Phone*

Email

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

The above information will be used for the following purposes:*

Planning appropriate treatment or program
Continuing appropriate treatment or program
Determining eligibility for benefits or program
Case review
Updating files
Other

CONSENT

Consent To Release Confidential Medical Information*

I agree to the privacy policy.

By signing below, I grant my permission for the release and exchange of information pertaining to my child’s medical, physical, educational and social/emotional condition and treatment between Ashley Johnson, M.S., CCC-SLP and the following parties. This may also include first hand observations of his/her speech therapy sessions by other speech-language pathologists.

HIPAA Notification*

I agree to the privacy policy.

I am required by law to maintain the privacy of protected health information, give you a notice of our legal duties and privacy practices regarding health information about your child, and follow the terms of this notice that is in effect as of 1-20-16 (attached pages).
By signing this document, you acknowledge receipt of the privacy policy (attached pages) as it relates to protected health information about your child’s treatment, payment and health care operations. You have the right to request restrictions, which must be made in writing to Ashley Johnson, M.S., CCC-SLP, of Speak Up Speech Therapy, LLC.

Date*

Signature*

Your relationship to client:*

Self
Parent / legal guardian
Developmental and/or social history
Personal representative
Other

I understand that this information may be protected by Title 42 (Code of Federal Rules of Privacy of Individually Identifiable Health Information, Parts 160 and 164) and Title 45 (Federal Rules of Confidentiality of Alcohol and Drug Abuse Patient Records, Chapter 1, Part 2), plus applicable state laws. I further understand that the information disclosed to the recipient may not be protected under these guidelines if they are not a health care provider covered by state or federal rules. I understand that this authorization is voluntary, and I may revoke this consent at any time by providing written notice, and after (some states vary, usually 1 year) this consent automatically expires. I have been informed what information will be given, its purpose, and who will receive the information. I understand that I have a right to refuse to sign this authorization. If you are the legal guardian or representative appointed by the court for the client, please attach a copy of this authorization to receive this protected health information.

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