Release of Information Consent Form

The Speech & Language Center at Stone Oak is authorized to send and receive client information, including correspondence, to or from the following persons or agencies:

Please complete new submission for additional providers needed.

With my signature below, I hereby authorize the release of client information to or from the Speech & Language Center at Stone Oak regarding the above client. Consent will terminate a year from today's date, by request, or if client is no longer receiving services at this clinic.