Release of Information Other

Release of Information Other
Name

First Name Last Name
I hereby give my permission for the release of information relevant to providing services and meeting my needs to the staff of the Sexual Assault/Spouse Abuse Resource Center, Inc. This release will be effective for the duration of my program participation.
Name/Agency
Relationship to Client
Phone #
Fax #
Via:

In-person Phone Fax Mail
It has been explained and I understand that any information released to a third party can not be guaranteed by SARC staff to remain restricted, as other agencies may not be bound by the same confidentiality requirements.

I understand that I can choose to revoke authorization to disclose at any time by signing the bottom of this authorization.
Client Signature and Date

Clear
I wish to revoke this Release of Information authorization at this time:
Client Signature and Date

Clear
Should be Empty: