Chippewa-Luce-Mackinac Community Action Agency
Senior Services Application
Consent to Disclose Release of Information
I hereby give consent and authorize the following agencies to reciprocate information to and with:
524 Ashmun St, Sault Ste Marie, MI 49783
Phone: (906) 632-3363 Fax: (906) 632-4255
The purpose of this consent is to Dislcose/Release of Information is to assist with senior service related issues. I (we) understand that I (we) cannot be denied assistance if we refuse to sign.
To revoke this consent, it must be in writing prior to the expiration date of 1 year after the release is signed.