Authorization to Exchange, Obtain or Release Information FundEd Chicago

Child's Name

Child's DOB

I wish to authorize FundEd Chicago to release information to and obtain information from the following persons/enities:

Persons/Agency's contact information:

Information to Be Released

Medical History

Evaluation and/or Therapy Notes

Academic Records (Evaluations, IEP/504 Plan, academic reports, etc.)

For the Purpose Of: (check all that apply)

Coordinating care with other professionals

Providing continuity of services

Updating therapeutic progress

I wish to place the following specific limitations on the information to be released:

I grant permission to exchange information via written and mailed report, phone call, meeting, email, or fax.

I understand that this authorization will remain valid until written revocation of this authorization is presented.

Parent/Gaurdian Name

Email address

Signature

Date

Your information will be encrypted.