WPCC AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION Logo
  • AUTHORIZATION FOR RELEASE/EXCHANGE OF CONFIDENTIAL INFORMATION

  • I,   *, hereby authorize the provider listed below to disclose certain protected health/education information of the student named below to officials of the White Plains Children’s Center for the purpose indicated below. If indicated, I also give permission to officials of the White Plains Children’s Center to disclose confidential education records to the provider indicated below.

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  • Outside Provider:

  • White Plains Children’s Center:


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  • Please read and initial the following statements:

  • I acknowledge that I may revoke this authorization by providing notice, in writing, to either of the persons/organizations named above at the address indicated above. I further acknowledge that such notice does not apply to information disclosed prior to either party receiving notice of my request to revoke this authorization.   *   

  • I acknowledge that this form was completed prior to my signing my name below.   *   

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