Futures Unwalled

FUTURES UNWALLED

Breaking Barriers & Building Futures
16787 Beach Blvd., #1005, Huntington Beach, CA 92647 | Phone: 714-253-4060
Release of Information
Requestor's Information

example: parent's name
Name

First NameLast Name
Relationship to child

Other
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
I authorize the release and exchange of information
Regarding (Child's Name)

First NameLast Name
Date of Birth

MonthDayYear
Date
between Futures Unwalled staff and the following person/agency:
Name of Program/Person Authorized to Exchange Information
example: name of school or person/people
Name of Program/Person Authorized to Exchange Information
example: name of school district or clinic
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Fax #
Please enter a valid phone number.Format: (000) 000-0000.
Information to be released

Other
Purpose of Release

Other
I understand this authorization remains in effect for one year after signing this document or when I revoke consent. I understand this authorization may be withdrawn any time in writing (except to the extent that action has already been taken). Further release shall cease (except as allowed by law) upon Futures Unwalled's receipt of the written revocation.
Signature
Name

First NameLast Name
Date signed

MonthDayYear
Date
NOTICE TO RECIPIENT OF PROTECTED HEALTH & EDUCATION INFORMATION Prohibition Against Re-Disclosure: This information has been disclosed to you from records protected by federal confidentiality rules. The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R., Part 2. A general authorization for the release of medical or other information is not sufficient for this purpose. The federal rules restrict any use of information to criminally investigate or prosecute any alcohol or drug abuse client. Drug abuse patient records are also protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), 45 C.F.R. parts 160 and 164. These conditions apply to every page disclosed and a copy of this authorization will accompany every disclosure.
Should be Empty:

Release of Information

Requestor's Information