Rand Speech Pathology doing business as

The Joshua Tree

Children’s Speech, Occupational , Physical Therapy Services

thejoshuatree.co

admin@thejoshuatree.co

Fax: 678-279-5430

AUTHORIZATION TO RELEASE MEDICAL RECORDS:

I authorize Rand Speech Pathology, LLC. to release the following documents ONLY to the person/entity/agency/insurance carrier listed below

PT, OT, Speech or Feeding Evaluations

Other evaluations on file

Hearing Test Evaluation

Discharge Summaries

ST, OT, PT Progress Notes

physician prescription/referrals

Treatment Plan

Other

Entity to receive health records:

Full Name

Street Address

City

State

Postal code

Country

Email *

Fax:

Please note: In order to maintain patient confidentiality:

1. Rand Speech Pathology does not have the authority to release records or information that we have received from another person/agency/entity/insurance carrier to any other party. In this event, the other party will need to directly request these documents from that person/entity/agency/insurance carrier.

2. Rand Speech Pathology. will not release records to any person/entity/agency/insurance carrier not listed. However, should you require that we do so, you must forward a signed request to release records with the same above information listed.

Signature of Parent/Caregiver

Clear

Date:

Client Name:

Date of birth

Relation to Client: