Health Information Release Form Child's First Name Child's Last Name My name below indicates that I hereby authorize the release and disclosure of protected health information to the following people on an as-needed basis as determined by CSA staff: Physician School Staff Daycare Staff Child Care Provider Individual Therapy Setting Related Professional Service Providers Attendant Family Member Custodial Foster Family Student SLP/SLP-Assistant Other Entity/Individual: Any individuals or entities that I do NOT want health information released to are listed specifically here: This authorization will EXPIRE upon discharge from patient services or upon my written request to deny future releases. I understand that I can revoke this consent at any time, except to the extent that action has already taken place and, if not expressly revoked earlier, this consent and authorization is valid until revoked by me in writing. Authorized RepresentativeI have read and fully understand the content of this consent and authorization release and hereby agree to and authorize the foregoing provisions. As used in this document, the terms "I", "me" and "my" may refer to the patient named above. Parent / Legal Guardian Name