903A South Greeley Highway, Cheyenne, WY  82007
307-633-8100  Fax: 307-633-8108 

RELEASE OF INFORMATION

Please sign and return this form only if you would like to designate any other person (i.e. spouse, mother, father, brother, family member, etc.) to inquire about the status of your care or your account.  Thank you.

 

SS # _____________________________________

I, ____________________________ give my permission for my ______________________,
         (name of patient)                                                               (relationship)

________________________________      to give and receive information regarding my care or
               (name)

account.   I give permission for Pain Consultants of the Rockies to speak to the above person on issues

concerning my care or account.

______________________________                                   ___________________
       (signature of patient)                                                             (date)

______________________________                                  ____________________                
              (witness)                                                                         (date)

|   BACK  |

Send mail to  webmaster with questions or comments about this web site.
Copyright © 2004 Pain Consultants of the Rockies, PC and Pain Treatment Center of Wyoming, LLC.