Authorization for Release of Information (Outgoing) Form

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:

Signature:[signature* signature-658*]

Agency:

Address:

City:

Zip:

Function of person or agency to which disclosure is to be made:

This information may be disclosed to the following:

Physician(s):

School District

Other:

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.

Signature:[signature* signature-659*]

Date:

Relationship to Client:

Client’s Name:

DOB: