Release of Information Form

This form allows Occupational Therapy Consulting Services to send and receive Evaluation
reports, and other requested information, including sending claims to your insurance provider. If
we do not have this form filled out, we will not be able to provide our services.

I hereby authorize any physician, clinic, hospital, institution or school to release Medical and
Psychological information regarding my child, to Occupational therapy Consulting Services. I
understand that this information is to be used for professional purposes only and that it will be
regarded as confidential. I also authorize Occupational Therapy Consulting Services to contact
any persons or institutions to obtain any additional information regarding my child, when

I hereby authorize Occupational Therapy Consulting Services to release therapy reports
regarding my child, to any entity or professional associated with my child’s care (physicians, any
clinic, hospital, institution, insurance company, school, and other).

The release of information consent will expire in 1 year or after all billing issues related to this treatment will have been resolved.

OPTIONAL: To give your child permission to be photographed and/or videotaped  for promotional or teaching purposes.