Release of Information from EBS to Another Entity

Parent or Guardian First Name*
Parent or Guardian Last Name*
Phone Number*
Email Address*
Child's Name*
Date of Birth*
MM slash DD slash YYYY
Home Address*
Street Address City State ZIP Code
Date of Request
MM slash DD slash YYYY
I hereby authorize EBS Early Intervention to release the information indicated below to the following entity:
Please check all information you would like to release:
- IFSP/IEP
- Evaluation Report
- Annual Review
- Medical/Developmental History
- Other
Please specify "Other":
All information released is for the expressed purpose of developing and integrating an effective plan of treatment for the above named child. I understand that this information is confidential and will only be viewed by professional individuals involved in my child’s care.

I understand that I have the right to cancel this authorization at any time.
Date
MM slash DD slash YYYY