Release of Information

Release of Information
This is a consent for release of information for:

First NameLast Name
Last 4 Digits of Social Security Number
Date of Birth

MonthDayYear
Date
DOVRColumbusDOEDOLDDDSDHSSMy past and/or current Employer3rd party entity:Other
I understand that I can revoke this consent in writing to both the person giving and the person receiving the information. Any information already released may be used as stated on the consent. I understand the requested or provided information is needed to determine and/or maintain services provided by AFPS.

This consent is valid until the last day of service provided by Ability Focused Professional Services.

Unless otherwise revoked and/or modified in writing sooner.

By my signature below, I affirm that I have read this release, or it has been read to me, and I understand its content.
Individual's Signature

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Date

MonthDayYear
Date
Guardian's Signature

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Individual's current, mailing or former address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Should be Empty: