I consent and agree that Early Start Therapy and its staff may contact me, leave voice messages, send me text messages and/or send me emails to the phone number(s) and email address(es) I have provided them. I understand that these messages can include protected health information, such as patient name, appointment information, billing information, information that identifies the practice as a therapy practice, and any pertinent clinical information. I understand that text messages and emails are not secure forms of communication and that by consenting to these communication types, I am waiving my rights to secure electronic communications. Early Start Therapy may send me informative emails that contain newsletters, information about treatment alternatives or other health-related benefits.
I hereby authorize and request that copies of my prior medical records be delivered to Early Start Therapy to establish or continue my health care treatment plan. This includes the complete assessment, most recent plan of treatment, progress summary, treatment notes and any other appropriately related documents or information.
I understand that for the purpose of continuing and coordinating my plan of treatment, Early Start Therapy may be asked to release copies of my medical records, or such portions thereof as may be relevant to evaluation or treatment services, or reports or summaries thereof, to other health care providers, facilities (related school or daycare staff, case managers, school system, CDSA, etc.) and appropriately related professionals involved in my care. My signature below indicates that I hereby authorize the release and disclosure of my protected health information to other individuals and institutions who provide care for my child on an as-needed basis as determined by Early Start Therapy staff.