Instructions:
Submitting this
form authorizes
(Agency and case worker Names):
to share certain
personal information collected about you or your family with
other non-profit, governmental, and volunteer organizations
participating in the 4People Case Management Network.
This agency may need
to share your information in order to coordinate services
and assistance, and to reduce the paperwork necessary for
you and/or your family to receive services and assistance
from multiple organizations. All organizations
participating in the 4People network are committed to
respecting your privacy and using your information solely
for the purpose of coordinating assistance provided to you.
With the exception
of certain limited circumstances, it is the policy of the
agency listed above not to release information about
individual or family assistance, or other personal
information obtained through the 4People network, without
the written consent of the individual or family. Therefore,
we need your written consent to share this information, as
required to assist you and/or your family, with other
4People network organizations.
I, Client (First & Last) Name:
Phone:
Address:
City: State:
Zip:
E-Mail:
herby
authorize the Agency listed in the block above to share any
of my information in its possession
with other non-profit, governmental, and volunteer
organizations participating in the 4People Case Management
Network in order to coordinate services and
assistance.
If you wish to
limit this release to specific information, please specify
the information that may be released.
Limitations to this release:
I understand that I may revoke this consent at anytime by
contacting the Agency listed in the block above, except when
action has already been taken to obtain and/or release such
information to organizations participating in the 4People
network.
By agreeing and submitting this
form, having read the above or had it read to me, I
understand the terms and conditions. I have also had the
opportunity to ask any questions. Additionally, I am signing
this release on behalf of my children that are under the age
of eighteen (18)
(First & Last) Name Head of Household
Name of Spouse
Name of Child #1
Age
Name of Child #2
Age
Name of Child #3
Age
Name of Child #4
Age
Name of Child #5
Age
Name of Child #6
Age
I Agree constitutes signature)
I do
not Agree
Once you submit this agreement a preview screen will come
up. If all of the information is correct, please print and
place in clients file BEFORE final submission.