Release of Information Authorization

Please review and complete this authorization form, then sign at the bottom.

Your Information

First Name *

Last Name *

Child Information

First Name

Last Name

Date of Birth

Release Information To

Who should we send your child's information to?

Recipient Name *

Organization

Address

Phone

Fax

Information to be Released

Select all that apply.

Purpose of Disclosure

This authorization is valid until

Leave blank if valid until revoked in writing.

Authorization & Your Rights

I authorize Raven Behavior Analysis to release the information selected above from my child's records to the recipient named in this form.

I understand that this authorization is voluntary and that I may refuse to sign. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and no longer protected by federal privacy regulations.

I understand that I may revoke this authorization at any time by submitting a written request to Raven Behavior Analysis, except to the extent that action has already been taken in reliance on it.

This authorization will expire on the date indicated above, or if left blank, will remain valid until revoked in writing.

Signature

By signing below, you confirm that all information provided is accurate and that you authorize the release of information as described above.