Change Inc Release of Information

1. Release of Information

I hereby authorize Change Inc to DISCLOSE protected information to the following agency as described below:I hereby authorize Change Inc to RECEIVE protected information from the following agency as described below:

Organization / Individual Change Inc. can communicate with (NOT client name):*

Email

example@example.com

Address:

Phone:

Fax:

I hereby authorize release of the following information (please check all that apply)

3. This authorization shall be in force and effect until

Optional expiration date:

or for 1 year, at which time this authorization expires.

4. revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization.

I understand I have the right to revoke this authorization, in writing, at any time. I understand that

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

I understand that my records are protected under the Federal Regulations governing Confidentiality of Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. This consent automatically expires at the end of one year unless otherwise indicated below.

Client Name (print)

Full Name*

First NameLast Name

Signature*

Date*

Date

Staff Signature:

Date:

Date

CHANGE INC