CLM-CAA Consent to Disclose/Release of Information

CLM Community Action Agency Housing Department

Consent to Disclose/Release of Information
Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
I hereby give consent and authorize the following agencies to reciprocate information to and with:

Chippewa - Luce - Mackinac Community Action Agency

524 Ashmun Street, Sault Ste. Marie, MI 49783

Phone: (906) 632-3363 Fax: (906) 632-4255

Please check all agencies that are NOT permitted to reciprocate information.
Select all agencies that are NOT permitted to reciprocate information.*

Chippewa County Health DepartmentSault Ste Marie Housing commissionDepartment of Health and Human ServicesHiawatha Behavioral HealthGreat Lakes Recovery CenterSault Tribe of Chippewa IndiansMichigan WorksMI Rehabilitation ServiceEUP Dispute Resolutions CenterNorthern Transitions IncorporatedAlger-Marquette Community Action AgencySalvation ArmyDiane Peppler Resource CenterUnited Way of the EUPWest Bridge ApartmentsVeteran ServicesBay Mills TribeCity/County Law Enforcement/Legal SystemLandlordUP SAIL Disability NetworkMedical Hospital/ClinicsOther
The purpose of this Consent to Disclose/Release of Information is to assist with housing/homeless related issues including behavioral. 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 one year from the date this form is signed.
Date

MonthDayYear
Date
Signature*

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Please verify that you are human*
Should be Empty:

CLM Community Action Agency Housing Department