Nyc Early Intervention Program Consent To Release/obtain Information Form printable pdf download

NYC EARLY INTERVENTION PROGRAM

CONSENT TO RELEASE/OBTAIN INFORMATION

Child’s Name:_____________________________________________ EI #:__________________DOB:___/___/___

Address: _________________________________________________________ Apt #:________________________

City/Town: ___________________________________ State: New York Zip Code:_________________________

I, (Parent/Guardian’s Full Name)_________________________________________, seek services for my child from the

NYC Early Intervention Program. I understand that the providers (including evaluators, service providers and service

coordinators) offering Early Intervention (EI) services to my child and family may need to exchange information to

develop and carry out the Individualized Family Service Plan (IFSP).

(Check one)

I authorize for the information below to be released

I authorize for the information below to be obtained

Specific information to be released/obtained:

EI Medical Form

Multidisciplinary Evaluation

Supplemental Evaluation(s) Specify: ____________________

_______________________________________

Individualized Family Service Plan

Provider Progress Notes

Session Notes

Other:__________________________________________________________________________

I authorize for the information to be (check/complete either A, B, or C):

Released to all EI providers providing evaluation, service coordination, or services to my child and family

B. Released to the Individual/Agency below:

________________________________________________ ______________________________________________

(Name/ Organization)

(Street Address, Borough/City, Zip Code)

(____)________________

(Telephone Number)

(Fax Number)

C. Obtained from the Individual/Agency below:

________________________________________________ ______________________________________________

(Name/ Organization)

(Street Address, Borough/City, Zip Code)

(____)_______________

(____)________________

(Telephone Number)

(Fax Number)

The information will be sent to:

________________________________________________ ______________________________________________

(Name/ Organization)

(Street Address, Borough/City, Zip Code)

(____)_______________

(____)________________

(Telephone Number)

(Fax Number)

D. The purpose of the requested information is to: (check all that apply)

Establish Early Intervention eligibility

Develop an Individualized Family Service Plan

Start, coordinate and monitor Early Intervention services

Inform the child’s physician about my child's services and

Other:_____________________________________________________________________________________

I understand that this release can be withdrawn at any time upon written notice to my Service Coordinator.

This release ends on the date of my next scheduled IFSP (or, if sooner, specify date _____/_____/_____).

Signed: _______________________________________ Date: ____/____/____

Relationship to Child: _________________________________

NOTE: A reproduced copy of this signed form is deemed to have the same force and effect as the original. A new Consent to Release Information form

must be signed at the initial IFSP meeting and at each IFSP review and annual meeting. Blank consent forms should never be signed by the parent.

Consent to Release/Obtain Information Revised 12/10

Nyc Early Intervention Program Consent To Release/obtain Information Form

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