Authorization for the Exchange of Information


To maximize the effectiveness of our evaluations, we would like to have the ability to contact other professionals working with our client. Unless sooner revoked, this consent expires six months after the last treatment or evaluation session.

I hereby authorize

Primary Care Physician (Name/Telephone #/Cell Phone #/Email)

Medication Prescriber (Name/Telephone #/Cell Phone #/Email)

Therapist/Psychologist (Name/Telephone #/Cell Phone #/Email)

School -- Teacher, School Psychologist, Principal (Position/Name/Telephone #/Cell Phone #/Email)

Another parent or guardian (Relationship/Name/Telephone #/Cell Phone #/Email)

Other (Relationship/Name/Telephone #/Cell Phone #/Email)

Other (Relationship/Name/Telephone #/Cell Phone #/Email)

to release and/or exchange

any and all pertinent information relating to to Western New England Integrated Learning Center, LLC (d/b/a Learning Solutions).

Leave this empty:

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Signature Certificate
Document name: Authorization for the Exchange of Information
lock iconUnique Document ID: 825f019ef397eb1f8a5f59680445188dad3d59ea
TimestampAudit
September 27, 2020 9:17 am EDTAuthorization for the Exchange of Information Uploaded by Leslie Roberts - leslie@learningsolutionsls.com IP 96.39.16.94
October 5, 2020 12:47 pm EDT Document owner leslie@learningsolutionsls.com has handed over this document to lroberts@learningsolutionsls.com 2020-10-05 12:47:47 - 96.39.16.94