Release of Information The exchange of information between medical providers encourages safe and efficient coordination of care for patients. This authorization is for release of verbal communication and exchange of written information:Patient Name(Required) First Last Patient Date of Birth(Required) MM slash DD slash YYYY DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.Primary Care Clinician(Required) Primary Care Clinician Primary Care Clinician(Required) School / School District School / School District School / School District Seattle Children’s Hospital Seattle Children’s Hospital Seattle Children’s Hospital Birth To Three Center Insurance Company Birth to Three Center Name Other Other Other Other Other Untitled Cascade Orthotics & Prosthetics Cascade Orthotics & Prosthetics NuMotion NuMotion Other DME Other DME Purpose or need for disclosure:(Required) Care Coordination Other Other Agreement(Required) I understand that the information obtained will be treated in a confidential manner and will not be transmitted to a third party without authorization. Legal Authority(Required) I have the legal authority as the patient parent / guardian to sign for the patient, who is a minor or who is unable to sign for themselves. I hereby authorize the release of records to / from: Valley Kids Therapy - Fax: 360-336-3492 Signature(Required) Date(Required) MM slash DD slash YYYY Authorization expiration: Standard expiration date will be one year from date of signature unless otherwise specified. CAPTCHAUntitledFirst ChoiceSecond ChoiceThird ChoiceCommentsThis field is for validation purposes and should be left unchanged.