Release of Information (English)

Release of

Information

Only needed if we are sharing your information with an outside group, organization, or individual

Please Read Carefully Before Proceeding

Before allowing 4 The Love Foundation to share your confidential information, their advocate will discuss the options, risks, and benefits with you. If you agree, use this form to specify what information is shared, how, with whom, and for how long.

First name

Last name

Email

I hereby grant permission to 4 the Love Foundation to disclose the following specific information with:

Name of Person

Agency's Specific Office

Phone Number

Method of Sharing Information (check all that apply):

In Person

By Phone

By Mail

By Email

Acknowledge that email is not secure and may be intercepted.

Details of Information to be Shared: (Please provide as detailed a list as possible, such as name, dates of service, and any pertinent documents).

Reason for Sharing Information: (Please specify the purpose as precisely as possible, for example: to access benefits).

Acknowledgments:

I am under no obligation to sign this release form and I have the right to decline sharing my information.

The decision to sign this release form is entirely voluntary.

This release is limited to the information provided above.

Should I wish for 4 the Love Foundation to release additional information about me in the future, I will need to sign another release form.

The disclosure of my information may reveal my location and confirm my receipt of services from 4 the Love Foundation.

Neither I nor 4 the Love Foundation may have full control over the subsequent handling of my information by the recipient agency or individual.

This release expires on:

Date and time

Month

Day

Year

Time

HoursMinutes

By signing this release, I acknowledge its validity and understand that I can revoke my consent at any time, either verbally or in writing.

Signature

Signature field is empty.

Today's Date

Month

Day

Year

Release of

Information

A 501(C)(3) nONPROFIT- EIN 84-3500182