Authorization for Communication of Client Information between another facility and FTS

Patient Name(s) *

Date of birth *

Patient Name(s) *

Date of Birth *

I hereby authorize personnel at *

Name of Facility

located physically at *

Street Address
City
State
Zip

To communicate back and forth freely with authorized employees of Fundamental Therapy Solutions, physically located at: 3312 S. Peoria Ave., Tulsa, OK 74105 Telephone: (918) 400-0089 Fax: (539) 430-0051, regarding the above-named individual’s therapeutically relevant information pertaining to:

Therapeutic progress
Records of therapy
Other

I understand that this authorization is voluntary and I may refuse to sign this authorization. I understand that authorization will expire, by law, 180 days from the date of this authorization unless I otherwise specify. This authorization will be in effect until

I understand that I may revoke this authorization by contacting Megan Atterberry at Fundamental Therapy Solutions. The revocation must be in writing.

Parent/Guardian (print)

Parent/Guardian Signature *

Clear

Date *