I, [Name of Individual or Individual’s Legal Representative]: Authorize Simple Health Services Inc. to disclose to Person Centered Housing Consultants, or Experience 61Indicate other types of records that will be released: Name, DOB, PMI, Phone #, Email Address, and PSN (If applicable)For the purpose of: Gaining Approval for Housing Stabilization Services This information will be used for: The purpose of obtaining DHS Approval for Housing Stabilization Services through Simple Health Services, Inc. I know that state and federal privacy laws protect my records. I know:● Why am I being asked to release this information?● I do not have to consent to the release of this information. But not doing so may affect this program's ability to provide needed services to me.● If I do not consent, the information will not be released unless the law allows it.● I may stop this consent with a written notice at any time, but this written notice will not affect information this program has already released.● The person(s) or agency (ies) who get my information may be able to pass it on to others.● If my information is passed on to others by this program, it may no longer be protected by this authorization.● This consent will end one year from the date I sign it unless the law allows for a longer period.