Consent for the Release/Request of Confidential Information

Speech Language Therapy Services Release

I/We ______(Name of Parent/ Guardian/Guardian ad litem),

authorizeSouthern Kennebec Child Development Corporation to disclose/receive the following information

Pertaining to: ______(Name of Child)______(birth date).

Town of Residence: ______

Specify all information to be or not to be released/requested by checking every one of the following boxes:

YES / NO / ITEM / YES / NO / ITEM
Child Observation Report / Plan of Care - Therapy
Evaluation - Behavioral / Nutrition/Diet History
Evaluation – Developmental / Physical exam report
Evaluation – Hearing / Plan of Care - Nutrition
Evaluation – Speech / Screening – Developmental (includes summary and ASQ-SE)
Health Information as related to disease and illness / Screening – Hearing
Health Intake Information / Screening – Speech
Health/Developmental Progress/Assessments / Screening – Vision
Evaluation – Developmental / Other, please specify:
Individualized Family Service Plan (IFSP)
Specific Information Requested:

Purpose: In order to assure that the above-named child has access to a complete health and developmental screening and follow up services.

Information is to be released to/from: Provider

Provider address: Telephone#:

Please read the following carefully.

  • I/we understand that this release permits SKCDC to communicate verbally, in writing and through fax as needed during the year with the Provider specified above. Cover sheets will contain a confidentiality statement. However, I understand confidentiality at the receiving end cannot be guaranteed.I/we understand that I/we have the right to refuse authorization for any or all of the above listed information. If other information is needed during the year, the parent will be notified of the specifics.
  • In granting permission, I/we understand that such information will remain in a confidential file and will be used for the benefit of the above named child. I/we understand that this file is available for my/our review upon request and that SKCDC adheres to the Family Educational Rights and Privacy Acts regarding confidentiality of client records.

I/we understand that I/we have a right to a copy of this consent form.

  • I/we understand that I/we may revoke permissions for the release/request of information at any time by notifying SKCDC, at the address above, except to the extent that previous action has been taken in reliance on it prior to receiving notice of revocation. This consent automatically expires one year from date of signature. I/we understand that services for the above named child, but will not affect my child’s eligibility for SKCDC programs.

Date______(Parent/Legal Guardian)

Date______(Child & Family Services Staff)