psls_Release

Child's Name
Date of Birth

MonthDayYear
Date
Release of Information
I, name , DO consent for the below listed individuals or agencies to share information with and receive information from Pediatric Speech and Language Services regarding my child child's name , for the purpose of evaluation and treatment.
Please include Family (other than legal guardians), Doctors (your child’s primary care doctor will have to sign off on a Plan of Care before therapy can begin), Daycare or School employees (if your child will be seen at daycare or school, teachers must be listed) and any others who need to participate in your child’s care. If there is no one who you would like for PSLS to communicate with please write None.

Clear
Permission is granted until 1 year following discharge UNLESS this release is revoked by written request.
Parent/Guardian Signature

Clear
Date

MonthDayYear
Date
Authorization for Electronic Communications
Pediatric Speech and Language Services, Inc. follows HIPAA confidentiality and privacy laws applicable to protected health information. Throughout your child’s treatment there may be times you wish for us to send information to you, your child’s school or doctor via test or email.

While PSLS will take precautions not to include identifiable information in text messages, we remind families that by the nature of health record documents, such as evaluation reports and therapy notes, some information like your child’s full name, birth date and diagnosis are present on the documents.
I DO or DO NOT consent Pediatric Speech and Language Services staff to use electronic communications to send, receive, and transmit information regarding my child.
Authorization for Video and/or Pictures
Circle as appropriate to grant permission to record your child’s voice and/or image as he/she participates in speech therapy to use for progress monitoring or training.
ParentGuardian Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Release of Information

Authorization for Electronic Communications

Authorization for Video and/or Pictures