Healthcare Speech PR Form

Healthcare Speech PR Form

Purpose: This form documents current speech-language pathology services, clinical findings, progress toward established therapeutic goals, and authorizes release of speech therapy progress reports, evaluations, and related clinical information as specified below. Completion of this form does not constitute clinical authorization for services; it is a clinical record and release/acknowledgement instrument.

Patient Information

Patient Name:

Male Female Non-binary Prefer not to disclose

Insurance / Payer Information

Referral & Reason for Evaluation

Referral Date:

Clinical Findings & Current Status

ICD-10 / Code (if applicable):   Onset Date:

Therapy Plan, Goals & Progress

Authorization to Release Speech Therapy Progress Reports

I authorize the disclosure of my speech-language pathology progress reports, evaluations, and treatment summaries to the recipient named below for the purpose identified. I understand that information disclosed under this authorization may include clinical observations, therapy goals, progress notes, and limited diagnostic coding. I understand that this authorization is voluntary and that I may revoke it at any time by providing written notice except to the extent that action has already been taken in reliance on this authorization.

Expiration Date of Authorization:   If no date entered, this authorization expires 365 days from signature.

Limitations (check any that apply):
Exclude behavioral health notes Exclude substance abuse treatment records Other limits (describe below)

HIPAA / Privacy Acknowledgment

I acknowledge receipt of the clinic's Notice of Privacy Practices describing the ways my protected health information may be used and disclosed. I understand that I have the right to request restrictions on certain uses and disclosures, to inspect and request copies of my health information, and to request amendment of my records to the extent permitted by law.

I acknowledge that I have received and reviewed the Notice of Privacy Practices.

Authorization Statement & Legal Notices

I authorize the disclosure described above. I understand that I may revoke this authorization at any time by submitting a written revocation to the clinic's medical records department, except for disclosures already made in reliance on this authorization. I understand that information disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal privacy regulations. I understand that I will not be required to sign this authorization as a condition of receiving treatment, except when the provision of health care is solely for the purpose of creating protected health information for disclosure to a third party.

I authorize the release of the described records as indicated above and certify that the information provided on this form is complete and accurate to the best of my knowledge.

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