690 E. Warner Rd. Ste. 105, Gilbert, AZ 85296  ||  Phone: (480) 820-6366  ||  Fax: (480) 820-0462

AUTHORIZATION FOR MUTUAL EXCHANGE OF INFORMATION

PURPOSE: To obtain child’s records and/or coordinating services.

I hereby authorize the mutual exchange of protected health information regarding the above-named child between Advanced Therapy Solutions and the following listed below:

My signature on this facsimile copy, scanned copy, pdf or other reproductions of this document shall be valid and binding. This release is effective for one year from the date of signature. Any person or agency receiving this information is directed to treat it as confidential.

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