Authorization for Obtaining Info

I, the undersigned, do hereby authorize the University of Arizona Speech Language and Hearing Clinics, on behalf of The Child Language Center, to obtain information from any agency or individual, as stipulated below, including pictures, audio or video tapes, who is or may be directly involved in the examination, treatment and/or recommendations concerning my child. I also understand that I have the right to revoke this authorization in writing at any time.

Note: This document is authorized by: (When initialing and printing your name, you are acknowledging the initials and printed name on these documents will act as your temporary authorization and we will require you to sign these documents in person):

Message

Today's Date

YYYY

Child's Name

First Name

Last Name

Home Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Enter Initials

This document is authorized by: (When initialing and printing your name, you are acknowledging the initials and printed name on these documents will act as your temporary authorization and we will require you to sign these documents in person):

Printed Name

Relationship to Child

Address (If Different Than Child)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Witness (Printed Name)

The individual or agency listed below is authorized to release the client/patient information to: The Child Language Center Wings on Words Toddler and Preschool Program 202 E. Speedway Blvd. Tucson, AZ 85705

Date

YYYY

Agency/Individual Name

First Name

Last Name

Address of Agency/Individual

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Info to Be Released

(ie: evaluation/progress reports, IEPs, etc)

Authorization for Obtaining Info

wings on words