Release Form – Woven Language + Learning

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Thank you for your response. ✨

Patient Name(required)

Date of Birth(required)

Disclosing Party (Client, parent or guardian)(required)

Recipient (person you would like Woven to communicate with)

Name/Type of Organization

Contact Person

E-mail/Phone

Personal Health Information (PHI) to be Disclosed (check all that apply)

Medical evaluations and treatment Academic performance and tutoring Psychological evaluations Psychological treatments Surgeries OT/PT/Speech-Language Therapies

Other (please specify)

Purpose of Disclosure (check all that apply)

Coordination of care Insurance claims/coverage School/Educational purposes Research At the request of the individual

Other

Expiration Date:

This authorization is valid for one year from the date of signature.

If sooner than one (1) year, this authorization expires on:

Patient Rights & Notices:

1. Patient may revoke this authorization in writing at any time, except to the extent action has already been taken.

2. Treatment, payment, enrollment, or eligibility for benefits is not conditioned on signing, except in limited

cases permitted by law.

3. Information disclosed may be subject to redisclosure by the recipient and may no longer be protected by HIPAA.

Signature and Date(required) (By typing my name below, I am electronically signing this document)

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