RELEASE FORM 1-2023

Authorization for the Release of Information

I would like to authorize the following agencies/physicians/organizations to obtain/release all information regarding therapy services to and from The Center for LifeSkills and Stefanie Peck, M.A. CCC-SLP for the purpose of providing the appropriate services and continuity of care.

(please fill in any and all that apply)
My chid's school districtSpecialistSLT/OT/OTOther provider
My Chid's School District:
Specialist's Name and Phone Number
SLT/OT/PT's Name and Phone Number
Other Provider
This authorization remains in effect until either party notifies the other in writing that it is terminated.
Regarding: Patient's Name
Date of Birth

MonthDayYear
Date
Signature

Clear
Name and Relationship
Date

MonthDayYear
Date
Should be Empty: