I authorize Remedy Speech Therapy and its associated health professionals and personnel to collect my/my child's personal and medical information. In addition, I authorize Remedy Speech Therapy and its associated health professionals to communicate with my/my child's family doctor and/or referring doctor and/or other health care providers as deemed necessary for my/my child's beneficial treatment. My/my child's information may be disclosed to my physician(s), my facility, payer sources, health insurance provider, or a third party electronic medical record provider, health care provider, school speech therapy provider, individual or entity covered by HIPAA regulations. I also understand that my personal and medical information is confidential and will only be disclosed to third parties as required for my care.

I authorize Remedy Speech Therapy to share information related to PHI (i.e., progress updates, evaluations, treatment plans, SOAP notes, etc.) with the facility/provider(s) listed above.

I authorize Remedy Speech Therapy to send relevant documents via email to the facility/provider(s) listed above.

I confirm that I have received a copy of the Notice of Privacy Practices, and I understand its contents, including: Use and disclosure of my health information, my rights related to my health information, how to contact the provider with questions or concerns about my health information.

I understand that my consent is required for certain uses and disclosures of my health information, as explained in the Notice of Privacy Practices. I consent to the use and disclosure of my health information for the purposes outlined in the notice.