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F 1 0 6 2 8 9 T win s b urg O H 44 0 87 3 30 - 4 0 5 -8 7 76 con t a ct p ea kpo t en t ia lt he ra py. Peak Potential Therapy LLC Speech Therapy with a Developmental Holistic Approach to Treating Children with Disabilities Authorization for Use of Disclosure of Protected Health Confidential Information Organization Name of Individual s Address City State Zip Client DOB I hereby authorize the disclosure or release of the following information check all that apply Social History Psychiatric...
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