Consent for Release of Information

Child's Name(Required)
MM slash DD slash YYYY

I hereby authorize Leaps And Bounds Therapy, LLC. to contact the health care providers, teachers and/or professionals set forth below, and obtain from those providers all information relating to my child (written or otherwise) which, in the opinion of Leaps And Bounds Therapy, LLC., will assist Leaps And Bounds Therapy, LLC. in the evaluation and treatment of my child. Such information may include, without limitation, “individually identifiable health information” as defined and provided in the Health Insurance Portability and Accountability Act.

Pediatrician's Name(Required)
Teacher's Name
Occupational / Speech / Physical Therapist's Name
Parent or Legal Guardian's Signature(Required)
By submitting this form and completing the signature field I agree that the information is truthful.