Sample Consent to Release Info

Agency Name or Letterhead here

SAMPLE
CONSENT TO RELEASE INFORMATION
I, [client name] __________________________________________, agree that confidential
information about me may be released to my advocate, [name] ______________________
______________________________, at [your organization’s name] ________________
_______________________________________________, or persons under my advocate’s
supervision. Unless otherwise arranged, all information and documents should be sent to the
business address where my advocate can be reached.
This release applies to the following individuals and/or entities:
[Name(s) of agency(s) from which you are requesting information.] _______________________
______________________________________________________________________________
______________________________________________________________________________
I understand that copies of this release form may be used in lieu of the original. I understand that
I can change my mind at any time about who has permission to see my papers by putting this
change in writing.
Signed: ____________________________________________ Date: ______________________
Identifying Information: _________________________________________________________
The DHS case #, e.g.