• Release of Information for GOCPYVS

  • 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: Governor’s Office of Crime Prevention, Youth, and Victim Services

    Relationship to Client: Certifying body of SARC AIP, to audit/monitor/evaluate records 

    Phone: (410)-697-9338
    Address: 100 Community Place 
                   Crownsville, MD 21032

  • 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.

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