Release of Information

Release of Information
Client Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I authorize WYO HELP to give and receive information from the individual(s) and/or organizations liste 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 requiest to revoke this authorization.
The following is authorized to receive information in order to provide me assistance
The following is authorized to receive information in order to provide me assistance
The following is authorized to receive information in order to provide me assistance
The following is authorized to receive information in order to provide me assistance
Signature of Client or Legal Guardian

Clear
Date

MonthDayYear
Date
Should be Empty: