• Evergreen Youth & Family Services

    Authorization to Receive or Disclose Confidential Information
  • I understand that records are protected under the law and may not be disclosed without written permission as provided by the law.  Note: A separate authorization is needed for each individual and/or agency

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  • Please enter below information regarding the individual or agency you are allowing Evergreen Youth & Family Services to share information with.

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  • I understand that I do not have to sign this authorization and that refusal will not affect my ability to receive services.

    I understand that I may revoke this authorization in writing at any time except to the extent that action has been taken/ or received has been disclosed prior to my written revocation.

    I also understand that once Evergreen Youth & Family Services Inc., has disclosed information I have authorized, Evergreen Youth & Family Services Inc., no longer has control over the information and the information might be re-disclosed by the person/agency authorized to receive this information.

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