Thrive Virginia

Healthy Families - 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,       , 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:
Address
Phone: 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.

 

Participant Name:

Leave this empty:

Thrive Virginia https://thriveva.org
Signature Certificate
Document name: Healthy Families - Consent and Authorization to Release Information
Unique Document ID: 9110f8a2a052958a922104d2fe336aef987e6133
Timestamp Audit
April 22, 2020 9:41 am EDTHealthy Families - Consent and Authorization to Release Information Uploaded by James Andrews - documents@thriveva.org IP 100.7.130.42