Release of Information Authorization Forms

  

Square One Specialists in Child and Adolescent Development abides by the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules.

To authorize information to be sent from an outside facility to Square One, complete and return: Authorization to release information to Square One


To authorize information to be sent from Square One to an outside facility, complete and return: Authorization to release information from Square One