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Information Authorization
and Release Form
(Acknowledgement Form)
This release form shall apply
to Roy Steinberg, PhD and all other persons
associated
with the CaregivingforCaregivers.com Internet site.
I understand
that this form authorizes Dr. Steinberg
to collect information about me over
the internet.
In particular, this form allows Dr. Steinberg, a geriatric
psychologist, to collect information in connection
with the "Online
Assessment" on his CaregivingforCaregivers.com
Internet site so that he can
do an initial screening
of my memory or overall cognitive functioning (the
"Assessment"). The information collected
will be used for such purpose at
the discretion of
Dr. Steinberg.
I,
being of legal age, hereby consent that the information
concerning me may
be used by Dr. Steinberg in connection
with the Assessment and further
consent to his providing
the Assessment report directly to ___________________
at the following email address: _______________________
and further
consent to any follow up conversations
Dr. Steinberg may have with ________________________
concerning my information or the Assessment.
I understand
that I may revoke this authorization at any time in
a writing
provided to Dr. Steinberg. I hereby remise,
release and forever discharge Dr.
Steinberg and all
other persons associated with the
CaregivingforCaregivers.com
Internet site from any and all claims that I could
have arising from the disclosure of any information,
as provided in this
Authorization and Release From,
including information that could be deemed
to be privileged,
confidential or otherwise private.
IN
WITNESS WHEREOF I have hereunto set my hand, in the
State of _______________, this____ day of __________,
20___
Name: (Print) ______________________________________
Signature: ________________________________________
Address: _________________________________________
City: __________________ State: _______ Zip:_________
Witness:
Name: (Print) ______________________________________
Signature: ________________________________________
Address: _________________________________________
City: __________________ State: _______ Zip:_________
Please fax the completed Authorization and Release
Form to Dr. Steinberg at
856-782-1944 in connection with your submission
for an Online Assessment.
To Print this Release Form, select File->Print, or click here for the pdf version.
If you would like more information
to email Dr. Steinberg.
Caregiving
For Caregivers
Roy Steinberg Ph.D.
Tel 609.458.2540
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