Authorization for Release of Information (Outgoing)
I, the undersigned, herby authorize the Santa Rosa RiteCare® Childhood Language Center to provide information from the records of the above-named client to the following person or agency:
Function of person or agency to which disclosure is to be made:
This information may be disclosed to the following:
The undersigned may withdraw this authorization upon written notice received by the Santa Rosa RiteCare® Childhood Language Center at any time prior to the release of the information. This permission will remain in effect until the client is no longer receiving services from the RiteCare® Center.
A copy of this authorization is available for the personal records of the undersigned.
Relationship to Client: