Name: Pediatric People
Price range: $

Patient Name*

First Last

Patient Date of Birth*

I authorize:

Joanie Leach, LPC
Pediatric People PLLC
11955 Dallas Parkway, Suite 400
Frisco, TX 75033

To disclose and/or obtain treatment information from the following:

Name*

Address*

Street Address City State ZIP Code

Phone*

Email

Authorization to Release Information*

I acknowledge that information about me may be released, discussed, or disclosed. I understand that my records are protected under Federal Regulations governing Confidentiality of Protected Health Information (PHI) under HIPAA and Confidentiality of alcohol and drug abuse patient records, 42 CFR Part 2 and cannot be disclosed without my consent unless otherwise provided for the regulations. I also understand that I may revoke this authorization at any time and must do so in writing and present this written revocation to my therapist. I understand that once information is disclosed as per my authorization, the recipient, in accordance with eh applicable laws and regulations, may re-disclose the information and it might not be protected by federal or state privacy regulations.

Parent or Legal Guardian*

First Last

Relationship to Patient*

Mother
Father
Legal Guardian

Signature*

Date of Signature*

CONSENT TO RELEASE INFORMATION