• I grant permission for John Tracy Center to obtain or discuss medical, audiological, developmental and/or educational data which will
assist John Tracy Center in its services to my child.
• I understand that the information contained in John Tracy Center reports may be transmitted by JTC to educational and/or medical
agencies and individuals, in cases where exchange of information will be beneficial for my child.
• I understand that John Tracy Center preserves the confidentiality of information in accordance with statelaw.
• This authorization is effective immediately.
• I understand that I may revoke this authorization in writing at any time.
• This authorization shall terminate when my child exits services with John Tracy Center.
• JTC will no longer be authorized to disclose information and records after that time without my consent.
• Photocopies/facsimile copies of this authorization shall be considered as valid asthe original.
• I further understand that I have a right to receive a copy of this authorization upon my request.

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me and my
child under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I
authorize you to use and disclose my child’s protected health information to carry out:
• Treatment (including direct or indirect treatment by other healthcare providers involved inmy treatment);
• Obtaining payment from third party payers (i.e., my insurancecompany);
• The day-to-day healthcare operations of thepractice.
I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains
a more complete description of the uses and disclosures of my and my child’s protected health information and our rights
under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may
contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how our protected health information is used and disclosedto carry
out treatment, payment, and health care operations, but that you are not required to agree to these requestedrestrictions.
However, if you do agree, you are then bound to comply with the restrictions.
I understand that I may revoke this cons