CONSENT TO RELEASE INFORMATION
Waiver of Confidentiality Form for Person with Disability
All information that has been gathered on a person is personal and private, and you are not required to release this information. Such information cannot be released without authorized written permission, except as required by law.
PERSON WITH DISABILITY:
Name: (1)_______________________________________________________ Date of Birth: ____/____/____
Address: (1)_______________________________________________________________________________
City:_____________________________________ State:____________________ Zip Code:______________
AUTHORIZED REPRESENTATIVE (If Applicable):
Name: (2)________________________________________________________________________________
Address: (2)_______________________________________________________________________________
City:_____________________________________ State:____________________ Zip Code:______________
I understand that the information in the record of the person above (1) is considered personal and private. However,
I GIVE MY PERMISSION FOR:
Name: (3)_________________________________________________________________________________
Address: (3)_______________________________________________________________________________
City:_____________________________________ State:____________________ Zip Code:______________
TO RELEASE TO:
Name: (4)_________________________________________________________________________________
Address: (4)_______________________________________________________________________________
City:_____________________________________ State:____________________ Zip Code:______________
THE FOLLOWING SPECIFIC INFORMATION: (5) _________________________________________________
TO BE RELEASED FOR THE SPECIFIC PURPOSE(S) OF: (6) __________________________________________
My permission to release this information will expire: (7)___________________________________________________
I understand that my permission may be cancelled at any time except when the information has already been released.
________________________________________________ _______________________________________________
(8) Signature of Person with Disability (Date) (9) Witness (Date)
For Authorized Representative Only (If Applicable)--
I understand that my permission to release this information may be cancelled at any time except when the information has already been released. The undersigned certifies that he/she is the authorized representative of the person listed above and has the authorization to sign on behalf of the person, either by court order, or by operation of law.
________________________________________________ ________________________________________________
(10) Signature of Authorized Representative (Date) (11) Witness (Date)
Form 1468/001 (2/05)
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