I,   , guardian of   , acknowledge that I have received a copy of the HIPAA Notice of Private Practices from Advanced Therapy Solutions.

I agree and authorize Advanced Therapy Solutions to release my child's Protected Health Information to the following persons to facilitate care. If at anytime you would like to withdraw, make changes, or update the persons listed, please let us know in writing and new form will be provided.

Please list any persons who are not permitted to receive any information regarding this child:

Is there any legal documentation stating this?YesNo      *Please note that we may need to view this document for verification

I authorize Advanced Therapy Solutions to contact me in the way indicated below:

Phone:YesNo        

Leave Message:YesNo        

Text Message:YesNo        

Email:YesNo        

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