Consent for Release of Records and Information

I, (Parent/ Legal Guardian Name)

hereby give Epicenter ABA permission to release records and information listed below for,

(Patient Name)

to the following individual(s)/company(ies):

Release 1

Name/Company (ie. Dr. X, Cleveland Clinic)

Address

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

Phone Number

Fax Number

Release 2 (if needed)

Name/Company (ie. Dr. X, Cleveland Clinic)

Address

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

Phone Number

Fax Number

Release 3 (if needed)

Name/Company (ie. Dr. X, Cleveland Clinic)

Address

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

Phone Number

Fax Number

Please enter a reason for which this disclosure is to be made: To aid in the collaboration of care and ABA treatment for my child.

Records and Information for Release
**All Records and Available Information**
Initial Evaluation
Quarterly Reports
Progress Notes
Discharge Summary
Other: please specify.
Please check the records and information you would like the above to release to Epicenter.

My signature below verifies I understand the following; I recognize my right to revoke this permission at any time. If I do not revoke this permission it will expire one year from the date it is signed. I reserve the right to inspect and copy the information to be disclosed. Failure to complete all information on this request form will result in a refusal to release records and/or information.

Parent/ Legal Guardian Signature(Required)

Parent/ Legal Guardian Name

Date
MM slash DD slash YYYY

Consent for Release of Records and Information

Release 1

Release 2 (if needed)

Release 3 (if needed)

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In-Home & Clinic Applied Behavior Analysis Therapy
Northeast Ohio
Cleveland, Ohio

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