Language
  • English (US)
  • Spanish (Latin America)
  • Image-155

  • Definition of Forms

    • Release of Information: This form is to be completed by the guardian for anyone you would like for us to speak or disclose any information to (ie. residential providers, family members, medical professionals, etc.).
      • For an individual that is presumed competent (their own guardian), a release must be filled out for parents if you would like for us to speak or disclose any information to them.
      • A form must be filled out for any emergency contact person we have on file, if you would like for us to speak or disclose any information to them.
      • A form must be filled out to give a doctor approval to relesae information such as medical protocols, allergy information, and any other medical related information.
    • Release of Information 
    •  - -

    • I,       , authorize Triangle, Inc. to obtain and/or release protected information from/to:

    • I understand that this release is valid only for the period of one year from the date of my signature and that I may withdraw myconsent at any time. The information to be released has been explained to me and I have had the opportunity to ask questions. I givemy consent voluntarily, without the threat of punishment or promise of reward. I have discussed this release with the person obtainingmy consent and have had my questions fully answered. I understand that I may withdraw my consent at any time without fear ofpunishment.

    • Clear
    •  - -
    • Clear
    •  - -
    • Clear
    •  - -
    • Save, Preview, and Submit 
    •  
    • Should be Empty: