Release of Information Share Release of Information Request Dear Health Care Professional:The patient named below is going to be seen at Hands on Therapy, Inc for an evaluation and/or treatment. We would appreciate receiving a copy of your records regarding your client to assist in our comprehensive review and assessment. If the child is going to be seen for a feeding problem, we would especially appreciate a copy of the growth curve or any other relevant reports be included with your records. Below is a release signed by the child’s guardian. If you have already sent this information as a part of your referral, please disregard this request. Please return a copy of this request with your records and keep the original. Thank you.Patient's Name: First Last Date of Birth: MM slash DD slash YYYY Guardian's Name: First Last Relationship: I HEREBY AUTHORIZE THE FOLLOWING HEALTH CARE PROFESSIONAL(S) TO RELEASE COMPLETE INFORMATION FROM THE MEDICAL, SCHOOL, SOCIAL SERVICE AND/OR PSYCHOLOGICAL RECORD OF THE ABOVE NAMED CLIENT/PATIENT TO: Hands on Therapy, Inc. 3065 College Rd. Fairbanks, Ak 99709 I understand this authorization will expire, without my express revocation, one year from the date of signing, or if I am a minor, on the date I become an adult according to state law. I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken based on it. I understand that revocation will not apply to information that has already been released as specified by this authorization or to my insurance company when the law provides my insurer with the right to contest a claim under my policy or the policy itself. I understand that authorization for the disclosure of this health information is voluntary and I can refuse to sign this authorization. I understand that treatment, payment, or eligibility of benefits can not be conditioned on the signing of an authorization, except as otherwise permitted by law. I understand that any disclosure of information carries with it the potential for an unauthorized re-disclosure and the information may not be protected by federal confidentiality rules.Name of Professional/Group:* Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone:Email: Guardian/Client Signature:*Please sign your name in the box above.NameThis field is for validation purposes and should be left unchanged.