Medical Records Release
Parent/Legal Guardian Name
I (the parent/legal guardian of the child listed below) authorize that the following Therapy Records are to be released to PlayRx.
Child's First Name
Child's Last Name
Child's Date of Birth
Documents to be released:
Current ST/OT/PT evaluations and plans of care.
Purpose of Release:
Establish therapy services with PlayRx.
Your name
Signature of Parent/Legal Guardian
*
Clear
Date of Request
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