Skip to content
Ausblick Therapie GmbH
Authorization for disclosure of medical information
The Legal Guardian authorizes the use and sharing of treatment and service information for the purposes of continuity of care, progress report and evaluation, and professional consultation with the...
Client's physician / developmental pediatrician
(Required)
Yes
No
N/A
Full Name of Individual or Institution
Email Address
Phone Number
Client's past / current teachers & autism specialist
(Required)
Yes
No
N/A
Full Name of Individual or Institution
Email Address
Phone Number
Client's past / current OT service provider
(Required)
Yes
No
N/A
Full Name of Individual or Institution
Email Address
Phone Number
Client's past / current SLP service provider
(Required)
Yes
No
N/A
Full Name of Individual or Institution
Email Address
Phone Number
Client's past / current ABA service provider
(Required)
Yes
No
N/A
Full Name of Individual or Institution
Email Address
Phone Number
Client's other provider
(Required)
Yes
No
N/A
Full Name of Individual or Institution
Email Address
Phone Number
Signature
Client Name
(Required)
First
Last
Client Date of Birth
(Required)
DD slash MM slash YYYY
Signature
(Required)
Date of Signature
(Required)
DD slash MM slash YYYY
Guardian Name
(Required)
First
Last