Consent for Release of Information (Incoming)
The undersigned hereby authorizes:
Person/Agency , and any institution, school, physician,
or professional to release information relating to the treatment and/or education of
Date of Birth
, to the Santa Rosa RiteCare®
Client’s Address Childhood Language Center and the institution, agency, school, physician, or professional. This authorization extends to the furnishing of copies of all or any part or parts of the records pertaining to the above client.
You are hereby released from all legal liability that may arise by providing any information requested from the Santa Rosa RiteCare® Language Center.
This permission will remain in effect until the client is no longer receiving services from the Santa Rosa RiteCare® Language Center.
Relationship to Client: