Release Form
Comfort Therapeutic Services LLC
1380 Energy Park Drive 102
Saint Paul MN 55108
PH: (952)-303-5803 | Fax: (952) 303-4451
info@comforttherapeuticservices.com
1380 Energy Park Drive 102
Saint Paul MN 55108
PH: (952)-303-5803 | Fax: (952) 303-4451
info@comforttherapeuticservices.com
Authorization for Release of Information
This Notice may be interpreted to you in other languages, if requested.
Today's Date
Client File #
Client Last Name
First Name
Middle Initial
Date of Birth
Best Contact Phone #
I hereby authorize to release information from my record as indicated below
Information Released From:
Name / Clinic / Provider / Hospital, etc.
Contact Name
Address
City / State / Zip
Phone #
Fax #
Email
Information Released To:
Agency Name
Staff Name
Address
City / State / Zip
Phone
Fax
Email
I understand that the specific type of information to be disclosed includes:
Other:
PURPOSE OF DISCLOSURE:
Other (please specify)
Authorized Signatures:
Parent / Legal Guardian / Authorized Person
Relationship to client
Date
CTS Staff Signature and title
Date
