Authorization to Release Professional Information

Date Of Birth(Required)
I hereby authorize the mutual communication/exchange of information regarding my child’s therapy between Pavo Behavioral Therapy and the following entities. Any information released or exchanged may not be disclosed to any other agency except those required by law.
Agency/Contact Person
Email
Phone Number
Fax
By signing below, I acknowledge the following:
    • I understand that this authorization is voluntary, and I have the right to revoke this authorization, in writing, at any time.
    • I understand that a revocation will not apply to any information that was already shared as a result of this authorization.
    • I understand that this authorization will automatically expire 30 days after the termination of services.

Signature


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