Fillable 7.29.15 Release Of Clinical Information From Clinic California State University, Fresno

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7.29.15 Release Of Clinical Information From Clinic California State University, Fresno

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California State University, Fresno
Speech, Language and Hearing Clinic
5310 North Campus Drive M/S PH 80
Fresno, California 93740-8019
(559) 278-2422 Fax (559) 278-5187
RELEASE OF CLINICAL INFORMATION FROM THE
SPEECH, LANGUAGE, AND HEARING CLINIC
Today’s Date: ____________________
Name of Client: _________________________ DOB: _____________________
Release of information to:
Facility/Person Name: _____________________________
Address: _____________________________
City, State, Zip: _____________________________
Phone Number: _____________________________
FAX Number: _____________________________
I, _______________________________ hereby give the Speech, Language, and
Hearing Clinic at California State University, Fresno, permission to release clinical
information regarding any speech, language, or hearing diagnosis or treatment
concerning ______________________________ that occurred between the dates of
___________ and ____________to the appropriate medical and educational agencies
to further his or her care and education.
This release is considered valid for one year from the date it is signed below.
_______________________________ __________________________
Parent/Guardian/Self (18 or older) Date
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7.29.15 Release Of Clinical Information From Clinic California State University, Fresno

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Completed 22 May 2020

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