I understand that my participation in the development (assessment/evaluation) and/or provision of comprehensive speech and language  services to me and/or my family member(s) may require the participation of other agencies or individuals.  I understand that it may be necessary for Chandler Speech and Language Services LLC and these agencies or individuals to disclose and/or release information and records to/from one another, as may be necessary for the planning and delivery of these comprehensive speech and language services. I further understand that I may be denied services if I refuse to consent to a disclosure of confidential information necessary for the purposes of assessment/evaluation and/or treatment.  I furthermore release all parties specified herein from any legal liability resulting from the release of this information, with the understanding that all parties involved will exercise all appropriate safeguards with this confidential information.  I hereby give my informed consent for Chandler Speech and Language Services LLC. and the following designated agencies and/or individuals to (1) disclose to one another AND (2) receive from one another confidential information & records in their possession related to services provided to me and/or my family member(s).  This authorization will remain in effect for 12 months from the signature date.  I understand that any cancellation of or modifications to this authorization must be made in writing and that I have a right to receive a copy of this authorization, which shall be as effective and valid as the original.  I also understand that I may revoke this consent at any time, except to the extent that action has already been taken in reliance upon it.  Furthermore, I understand that such revocation of consent to release confidential information and records will result in the immediate discontinuation of all services provided by Chandler Speech and Language Services LLC.

  • Agency/IndividualContact Phone, Address, Email 
  • Date Format: MM slash DD slash YYYY
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