Healthy Families – Consent and Authorization to Release Information

Healthy Families - Consent and Authorization to Release Information

Healthy Families - Consent and Authorization to Release Information Document
  • *Text of Document
    Consent and Authorization to Release Information

    In order to develop a plan of service, Healthy Families at times, may require information from medical and other sources. At all times we are committed to safeguarding your rights and well-being. In order to give you the prompt expert help you require, we ask you to consent to the release of such information as will be necessary in planning intervention. The information will be private and confidential.

    I,    {Particpant Name}   , give permission for the following agencies to release and/or receive information regarding my child/children and myself to/from Charles City/New Kent Healthy Families.

    Agency:    {Agency Name}   
    Address:    {Agency Address}   
    Phone:    {Agency Phone}   
    Fax:    {Agency Fax}   

    This contract is to remain in effect for the duration of services and is for my protection. This consent is subject to revocation upon my written request, as of date of receipt by Charles City/New Kent Healthy Families.