ISOS- Release of Information Form

Islamic Social Services of Oregon State (ISOS)
Release of Information Form

Please review and sign to authorize the release of information.
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
I give permission to Islamic Social Services of Oregon State (ISOS) and the following service agencies listed below to share and exchange information for the purpose of providing assistance to me.
List Names of Agencies:
I confirm that my sponsor, named here, has explained the purpose of this form to me and I understand its content. My signature indicates my consent.
Sponsor Name:
Exceptions.
The only time Islamic Social Services of Oregon State (ISOS) staff would share information without my permission is when there is:
• Evidence of child or elder abuse or neglect
• A resident presenting a danger to themselves or others
• A court order requires disclosing the information
Today's Date

MonthDayYear
Date
Signature
This authorization is valid for one (1) year from the date of signature.
Client's Email:
example@example.com
After submission, you will receive a signed PDF copy of this form by email. This form is not automatically added to your application. Please forward this email with the PDF attachment to your sponsor. Your sponsor must upload the form as part of your application—submission of this form alone does not complete this requirement.
Should be Empty:

Islamic Social Services of Oregon State (ISOS)