Our House, Inc.'s Informational Referral Form

Authorization to Release Information
I hereby authorize First Name Last Name, (Name of Person making referral) to disclose to Our House, Inc. my name and/or function of the person or entity to whom disclosure is made for (student/staff/community):
The following protected/confidential information

Conversation NotesPolice FileRequested NeedsFamily memberOther
I understand that I have a right to receive a copy of this authorization, and that either any cancellation or modification of it must be in writing.

I understand that I have the right to revoke this authorization at any time unless the Provider has taken action in reliance upon it.

I also understand that such revocation must be in writing and received by the Our House, Inc. to be effective.
I authorize the disclosure of the protected information described above for the following purpose:
The Provider is authorized to disclose the protected health information specifically listed above until:   Date   (authorization expiration date).

Referral Person's Signature   Today's Date   Date

Witness' Signature:   Signature      Date
Please add any additional notes. (Optional)
Please attach any supporting documents (If applicable)

Cancelof

Disclaimer

15JOVW-23-GG-04473-HBCUSubgrantee award number: 23-001This project was supported by Grant No. 15JOVW-23-GG-04473-HBCU awarded by the Office on Violence Against Women, U.S. Department of Justice. The opinions, findings, conclusions, and recommendations expressed in this publication/program/exhibition are those of the author(s) and do not necessarily reflect the views of the U.S. Department of Justice, Office of Violence Against Women.
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