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

Fill Online, Printable, Fillable, Blank 7.29.15 Release Of Clinical Information To Clinic California State University, Fresno Form

Use Fill to complete blank online CALIFORNIA STATE UNIVERSITY, FRESNO pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

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

On average this form takes 3 minutes to complete

The 7.29.15 Release Of Clinical Information To Clinic California State University, Fresno form is 1 page long and contains:

  • 0 signatures
  • 0 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

U.S.A. forms for California State University, Fresno

BROWSE CALIFORNIA STATE UNIVERSITY, FRESNO FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
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 TO THE
SPEECH, LANGUAGE, AND HEARING CLINIC
Today’s Date: ____________________
Name of Client: _________________________ DOB: _____________________
Release of information from:
Facility/Person Name: _____________________________
Address: _____________________________
City, State, Zip: _____________________________
Phone Number: _____________________________
FAX Number: _____________________________
You have permission from ___________________________ to provide the Language,
Speech, and Hearing Clinic at California State University, Fresno, with copies of all
records pertaining to medical history and diagnostic services rendered or treatment
given to ___________________________ from the dates of ____________ to
____________. Released information regarding the above named person is for the
purpose of determining the most appropriate treatment for him/her. These records
will be released only to authorized personnel in the clinic, including faculty
members, clinic staff, licensed supervisors, and student clinicians. This release is
considered valid for one year from the date it is signed below.
_______________________________ __________________________
Parent/Guardian/Self (18 or older) Date
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

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

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 22 May 2020

Message

View Audit Log
Print With Audit Log
Duplicate Document