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Agency Name: _____________________________ Telephone #:________________
Address: _________________________________
_________________________________
Client's Name: _____________________________ Medicaid ID Number:______________
Address:__________________________________ Date of Birth: ____________________
__________________________________
Telephone Number: __________________________
I, ________________________________(print client's name), give consent for
_________________________________ (print name of care coordination provider) to release health/social services information to, and obtain information from,
__________________________________(print name of other provider/agency to which, or from which, you are requesting information) for the person named above. The information is to be used to assist me in monitoring and coordinating health care and social services.
The information to be disclosed includes:
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
Do not disclose the following information:
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
This authorization shall be valid from the signature date until _________ (print the date), and may be revoked by me at any time (except as it has already been used).
Client Signature: ________________________________ Date: ___________________
Parent/Guardian Signature: ________________________ Date: ____________________
Witness Signature: ______________________________ Date: ____________________