Pender United Release of Information
Authorization to Use and Disclose Confidential Information
I authorize Pender United, to disclose and exchange information to partner agencies in support of the needs my household:
Yes
No
Regarding (Client Name)
First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Email
example@example.com
Signature
Purpose of Disclosure- Select one
Clothing
Utility Assistance
Food
Other ______________________
Rental Assistance
Additional information
Select one of the following
This authorization is valid for one year from date signed
This authorization will expire upon the disposition of the crisis assessment / crisis intervention & coordination of care .
This authorization will expire when (specify below)
This authorization will expire on (specify below)
Signature
Date signed
-
Month
-
Day
Year
Date
Submit
Should be Empty: