Authorization for the Release of Information

Name of Agency/Physician/Organization/School*
You are authorized and requested to release and/or receive the following information:
- All Available Information
- Medical Reports
- Educational Reports
- Other
Regarding
Patient’s Name*
Date of Birth*
to The Center for LifeSkills and Stefanie Peck, M.A. CCC-SLP for the purpose of providing the appropriate services and continuity of care. This form will remain in effect until it is rescinded by either party.
Signed:
Name and Relationship*
Date*
Comments
This field is for validation purposes and should be left unchanged.