Release of Information Form

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    1. The following gives authorization for Gold Speech, Inc. to share or receive records and information about:

    with the following healthcare providers:*

    Additional providers:

    2. Select any other providers with whom we may share information, such as a developmental pediatrician, ABA provider or BCBA, psychologist, occupational therapist, teacher or school director:

    3. I understand that the information used or disclosed may be subject to re-disclosure by the person or class of persons or facility receiving it.

    4. I may revoke this authorization by notifying Gold Speech, Inc. and my therapist in writing of my desire to revoke it. However, I understand that any action already taken in reliance on this authorization cannot be reversed, and my revocation will not affect those actions.

    5. This authorization expires on OR upon occurrence of the following event that relates to the client: