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