Fillable Consent to Release Information to a Person or

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Consent to Release Information to a Person or

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Consent to Release Information to a Person or Agency
By signing this form you are giving your consent for Stroh Health Care to share relevant information as it
pertains to your participation in the Responsible Driver Program.
I,
DL#:
Birthdate:
give Stroh Health Care permission to provide relevant information as it pertains to my participation in the
Responsible Driver Program to
________________________________________________________________________
Name of authorized person or agency (translator/helper) and their contact phone number.
I understand that this information will be used to assist in the development of an appropriate program
plan. I also agree to allow the above named person/agency to provide relevant information to Stroh Health
Care as it pertains to my participation in the Responsible Driver Program.
Client Signature Date
Please mail or fax this document to Stroh Health Care.
Rev. 112017
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Completed 13 June 2022

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