1. CONSENT TO RELEASE INFORMATION
    2. Waiver of Confidentiality Form for Person with Disability
      1. PERSON WITH DISABILITY:
      2. AUTHORIZED REPRESENTATIVE (If Applicable):
      3. TO RELEASE TO:
      4. For Authorized Representative Only (If Applicable)--


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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