Consent Form
The University of Arizona Speech-Language and Hearing Clinics are committed to protecting your health
information. I have been given the Notice of Health Information Practices pertaining to how my personal
health information will be used. As my child’s guardian, I have the right to request restrictions on the
use of his/her health care information and can revoke this consent in writing at any time. I understand
that I can receive a copy of my child’s initial report, therapy plans, and end-of-semester progress
reports.
I understand that a role of this facility is as an educational training site for students in speech-language
pathology and audiology. Evaluation and/or therapy could include the participation of student clinicians,
parent observers, and other health care personnel.
I understand that my child’s speech and language objectives may be posted in his/her classroom and/or
on stickers placed on his/her clothing to facilitate generalization in the classroom.
I consent to the release of my health information to be used for the treatment, payment and health care
operations of the University of Arizona Speech-Language and Hearing Clinics.
Note: (When printing your name, you are acknowledging the printed name on these documents will act as your
temporary authorization and we will require you to sign the documents in person)