Client Release of Information (ROI)
Entity Name: Hines Employment Agency (HINES)
Name (Participant)
First Name
Last Name
Authorization to Disclose Information
By checking here, I acknowledge my partnership with Hines Employment Agency (HINES) to receive employment services/supports. I will work with HINES in collaboration with my Service Coordinator, Personal Agent, or Vocational Rehabilitation Counselor (if receiving services through VR). I will allow HINES to fulfill their responsibilities of the Service Agreement or VR Agreement.
Additional Authorization
By checking here, I also give HINES Employment Agency permission to speak with the following individual(s) mentioned on this form:
Please list names and their relationship to you here:
Is there any specific information NOT to release?
*
Yes
No
Information you wish to NOT release:
Agreement:
I understand that this information is confidential and protected by law. I have the right to revoke this consent at any time in writing, except to the extent that action has been taken based on this authorization. This authorization is valid for one year from the date of signature unless otherwise specified. I am signing this authorization of my own free will.
Signature
*
Date
*
-
Month
-
Day
Year
Date
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Should be Empty: