1334 E Chandler Blvd Ste 5-02
Phoenix, AZ 85048
Phone: 480.518.1535 | Fax: 480.718.7633
kathy@chpt.us |
caringhandspediatrictherapy.com

AUTHORIZATION TO RELEASE HEALTHCARE INFORMATION

Child's Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

I request and authorize Caring Hands Pediatric Therapy, LLC to release healthcare information of the patient named above to:

Parent's Name

First Name

Last Name

Date

MM

DD

YYYY

Signature