Disability Advocacy Client Release of Information
Date:
Client Name:
Date of Birth:
Client Address:
I hereby authorize (Name of Organization/Individual releasing information):
To release the following information to (Name of recipient/agency):
Description of information to be released:
Purpose of release:
This authorization will expire on (date/event):
Additional limitations or instructions:
Signatures
Client Signature:
Date:
Witness or Guardian Signature (if applicable):
Date: