Consent To Release Confidential Information

Consent To Release Confidential Information
Consumer Name:*

First NameLast Name
Legal Representative Name ( if Applicable):

First NameLast Name
Consumer Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Consumer Telephone Number:*
Please enter a valid phone number.
Agency Staff Name:

First NameLast Name
Staff Email:
example@example.com
Staff Telephone Number:
Please enter a valid phone number.
I authorize the release if any document generated by connext care and any other documents that are contained in my file to Vocational Rehabilitation, Department of Children and family and within the CC agency. This may include, but not limited to, medical reports, individual support plan' psychological reports, social service reports and academic records.
Release Start Date:*

MonthDayYear
Date
Release End Date:*

MonthDayYear
Date
Consumer Signature:

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Guardian Signature (if Applicable):

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Agency Representative Signature:

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Todays Date:*

MonthDayYear
Date
Should be Empty: