Medium

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Therapist Release of Information Mobile App

If a therapist feels medical information may be useful to the therapy and health care of a particular patient, the therapist may request patient authorization of access to records through a release of information.

This application is a simple therapist release of information form for a child. This form requires a child and parent signature, both of which can be captured within the app itself. With the completion of this form, medical records can be released to the therapist.

  • Lendlease
  • The Cooperative
  • PG&E
  • Red Bull
  • Mirvac

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Take a peek inside the Therapist Release of Information Mobile App

Included Features

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Client Name

  • Ico textbox

    Child's Name

  • Ico textbox

    I, Client as a parent/guardian of Child hereby authorize HEALTHY FAMILES OF ALBUQUERQUE, LLC and/...

  • Ico textbox

    for the purpose of: Assessment, Treatment Planning, Evaluation, Court Requirements and/or other r...

  • Ico date

    I understand that authorization shall remain valid from the date of my signature below and for th...

  • Ico statictext

    I have been informed that I may revoke this authorization by written or oral communication as doc...

  • Ico signature

    Signature of Client

  • Ico date

    Date of Authorization

  • Ico signature

    Signature of Parent/Guardian

  • Ico date

    Date of Authorization

  • Ico signature

    Signature of Parent/Guardian

  • Ico date

    Date of Authorization

  • Ico signature

    Signature of Witness

  • Ico date

    Date of Authorization

  • ...and More!

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