I the undersigned, herby consent to the release of information of Support Plan
and communication between Central Care Services.
(Specify information to be disclosed)
I understand that Central Care Services, Inc. and its employees and independent
contractors will not disclose information about me which is not legitimately involved in
the specific issue(s) stated above. The information released must be pertinent to
This consent is effective from Date 10/01/2020 To 10/01/2021.