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Release of Information - Baltimore Therapy Center
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First Name
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Your answer
Last Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Name the individual/organization information may be shared with:
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Your answer
I hereby authorize the Baltimore Therapy Center to disclose to & receive from the above-mentioned individual/organization the following information:
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All information relevant to my case.
Only that I am in treatment.
Other:
The other person/organization's phone number is:
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Your answer
The other person/organization's fax number is:
Your answer
The other person/organization's email address is:
Your answer
Electronic signature: Please type your name below.
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Your answer
I understand that my typed name above will act as my electronic signature. I understand that this authorization shall be voided at the termination of therapy, or at any such time as I choose to revoke it in writing.
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I agree
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