Release of Information

Release of Information
Client Name*
Email
example@example.com
Phone Number*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County of Residency*

Carbon County WyomingCrook County WyomingGoshen County WyomingNiobrara County WyomingWashakie County WyomingWeston County Wyoming
I authorize WYO HELP to give and receive information from the individual or organization listed below. i understand that information to be shared is limited to that which is relevant to receiving assistance from WYO HELP. This release will expire after 1 year or unless I make a written request to revoke this authorization.
Name of Person, Vendor or Organization to share your information with (Do not enter WYO HELP)*
Not WYO HELP. This is the entity we would share with.
Phone Number

Area CodePhone Number
Signature of Client or Legal Guardian*

Clear
Date*

MonthDayYear
Date
Should be Empty: