Information Release Form (Optional) - Rock Therapeutic Service

Patient’s Name*

Birth Date*

I request and hereby authorize Rock Therapeutic Services to*

Receive
Release

healthcare information of the patient named above from/to*

This request and authorization applies to*

Healthcare information relating to the following treatment, condition, or dates
All healthcare information
Other

If patient is a minor (17 or younger), Patient or Guardian's name*

Signature*

Patient’s Name (if 18 or older) or Guardian’s Name (if patient is 17 or younger)*

*

by checking this box and typing your name above, you are signing this form electronically. You agree that your electronic signature is the legal equivalent of your manual signature.

Date*