Information Release Form!

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This form is to allow the RMT to release your information for purposes such as inter collaboration between health care professionals, to facilitate the clients care, or settle employment or legal issues relating to the illness of injury etc. A) Patient Information Last Name First Name I am (Please circle one) Client
*Client Representative must sign in the event that the child is under the age of majority*

Client Representative

If you are the Client Representative please fill in the following:

Name:

Relationship to the Client:

Reason for Representative (under age of majority, physical or mental disability etc.)

Phone Number (XXXXXX-XXXX) Address (including city, province and postal code)

Date of Birth (YYYY/MM/DD)

Adapted and Developed from: http://www.health.gov.on.ca/english/providers/legislation/priv_legislation/sample_consent.html In accordance to the Health Information Protection Act, 2004 http://www.cmto.com/policies/release-of-records/ In accordance to Release of Records Policy from the CMTO, Revised July 7th, 2000 Created By: Pamela Makela

Information Release Form!

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Condition, complaint or Reason for Seeking Massage Therapy ! B) Therapist and Clinic Information Registered Massage Therapist Address of Clinic (including city, province and postal code) Date of Information Release Request (YYYY/MM/DD)

Please note that this Information Release Document is valid for 6 months following the date. After this date the form becomes void and will be kept with the released documents, returned to the patient or destroyed. In the event that information must be released passed the 6 months after the signing of this document the patient will be contacted to sign another form in accordance with the CMTO Release of Records Guidelines.

Valid Until (YYYY/MM/DD) +,%-.!#//!0,#0!#11/2! ! !

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Adapted and Developed from: http://www.health.gov.on.ca/english/providers/legislation/priv_legislation/sample_consent.html In accordance to the Health Information Protection Act, 2004 http://www.cmto.com/policies/release-of-records/ In accordance to Release of Records Policy from the CMTO, Revised July 7th, 2000 Created By: Pamela Makela

Information Release Form!

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I, _____________________________, authorize______________________________
(Print your name) (Print name of RMT )

to disclose all information checked above and I understand the purpose for disclosing this personal health information to the person noted above. I understand that I can refuse to sign this consent form.
Disclaimer: through signing this document I verify that all the information is correct and current in regards to the patient to the best of my knowledge. I understand that there is a fee for the release of these documents and that this fee must be paid prior to the release of any documents that are requested.

Signature

For Office use only. Fee: $20.00 Form of Payment: (Circle one) Date of Payment made: (YYYY/MM/DD) Report Release Date: (YYYY/MM/DD) Cash Cheque VISA Debit

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Adapted and Developed from: http://www.health.gov.on.ca/english/providers/legislation/priv_legislation/sample_consent.html In accordance to the Health Information Protection Act, 2004 http://www.cmto.com/policies/release-of-records/ In accordance to Release of Records Policy from the CMTO, Revised July 7th, 2000 Created By: Pamela Makela