INFORMATION RELEASE AUTHORIZATION
I,__________________________________________________________________, authorize Roger N. Meyer of "…of a different mind" to exchange information with and receive information from:
Person and/or agency:_________________________________________________
Address:____________________________________________________________
Phone:_____________________________ FAX_________________ _________
Email:_____________________
The following checked items indicate information to be exchanged or released. (Please strike out items not requested.)
____ Family History
____ Military Personnel records (non-medical)
____ Court records in possession of public authorities
____ Client/Attorney protected records
____ Social and family history
____ Complete educational/school records
____ Criminal records (background checks, police reports, parole or probation reports)
____ Employment history
____ Rental and housing history
____ Credit and personal finances history, including financial management/payee services
____ Vocational rehabilitation records
____ Other specify):__________________________________________________________
This authorization is valid while receiving services from Roger N. Meyer, and for ninety days following cessation of services and close of my case file, unless my consent is withdrawn, in writing, or unless a date is otherwise specified below.
Date specified (if any):___________________________________________
I understand that by signing this completed form, I will allow the sharing of confidential information with the person and/or agency listed above. With my written permission, this information may be redisclosed by Mr. Meyer to others, including Social Security Disability Determination Services and other benefits eligibility determination authorities.
___________________________________________________________________
Client signature(s) Date
___________________________________________________________________
Client parent/guardian/legal representative signature Date
if client is a minor or otherwise not competent to authorize release.
___________________________________________________________________
Signature, Roger N. Meyer, DBA "..of a different mind" Date
Release Form 2-05-05 OADM
