R2R Rider Intake Form

Please complete this form to the best of your ability, the more detailed you can be the better. All personal information provided is private protected information and will not be shared with any outside source. The provided information regarding your injury, medical process, and wellbeing will be used to create your R2R Fund portal where your friends, family and fans can read your update and donate to your cause tax free.


Rider Intake, Consent Authorization & Release Consent & Grant Payment

Step 1 of 3 - Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

  • 1. Authorization to Release and Disclose Patient Information The Road 2 Recovery Foundation

  • A. Patient Information
  • Date Format: MM slash DD slash YYYY
  • B. Authorization of Release of Protected Health Information
  • By typing your name you are certifying this is a legal signature.
  • Date Format: MM slash DD slash YYYY
  • C. Revocation
  • D. Not Restriction on Treatment
  • E. Further Disclosures
  • F. Road 2 Recovery Hold Back