Authorization for Release of Information

Authorization for Release of Information
I,Name* , hereby authorize
(Name of individual, health care facility, financial institution or other)
to release a copy of the following record(s) or information: *
I voluntarily request that the information be released to:*
Name or person/organization receiving the information.
I agree to hold harmless Triangle, Inc., its officers, and all other persons connected with the organization from any liability for releasing this information pursuant to my request.
Signature of Authorization (individual and/or guardian)*

Clear
Printed Name of Person Signing Above*
Telephone Number*
Format: (000) 000-0000.
- Please enter an email to receive confirmation that this form was submitted successfully, and to receive a copy of the form.
  example@example.com
- Should be Empty: