Release of Information
Please complete this form to authorize The Rusted Rock to communicate with members of your support team. This authorization helps promote collaboration, continuity of care, and coordinated support.
Your Information
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact
Please provide the individual you would like The Rusted Rock to contact in the event of an emergency or urgent safety concern. Information shared will be limited to what is reasonably necessary to address the situation.
Emergency Contact Name
*
Relationship to Emergency Contact
*
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Email Address
*
example@example.com
Trusted Contact
As part of working together, The Rusted Rock asks each client to identify a trusted contact or support person who serves as a collaborative member of their support network. I authorize The Rusted Rock to communicate with the individual listed below regarding the topics I have selected in this Release of Information.
Trusted Contact Name
*
Relationship to Trusted Contact
*
Trusted Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Trusted Contact Email Address
*
example@example.com
I authorize discussion of the following (select all that apply):
*
Attendance and participation in services
Scheduling and appointment coordination
General support and encouragement
Implementation of goals and support planning
Coordination of care with providers
Billing/payment questions (if applicable)
Other
If Other, please describe.
Provider Contact
I authorize The Rusted Rock to communicate and coordinate with the provider identified below regarding my care, goals, progress, treatment recommendations, and services as reasonably necessary to support continuity of care and collaboration.
Provider Contact Name
*
Relationship to Provider Contact
*
Provider Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Provider Contact Email Address
*
example@example.com
Additional Contact (Optional)
If you would like The Rusted Rock to communicate with an additional individual or organization not listed above, please provide their information below. Communication will be limited to the purpose(s) authorized in this Release of Information.
Other Contact Name
Relationship to Other Contact
Other Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Other Contact Email Address
example@example.com
I authorize discussion of the following (select all that apply):
Attendance and participation in services
Scheduling and appointment coordination
General support and encouragement
Implementation of goals and support planning
Coordination of care with providers
Billing/payment questions (if applicable)
Other
If Other, please describe.
Sign & Date
Expiration
*
This authorization remains in effect until revoked in writing.
Revocation
*
I understand that I may revoke this authorization at any time by providing written notice to The Rusted Rock. Revocation will not apply to information already disclosed prior to receipt of my written request.
Signature
Date
-
Month
-
Day
Year
Date Picker Icon
This authorization applies only to the individuals and organizations identified in this form and only for the purposes described above.
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