Release_of_Information_Form_FROM OOH
The execution of this form does not authorize the release of information other than that specifically described below. Your disclosure of the information requested on this form is voluntary
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Email *
I __________________(NAME)
Social Security #
Date of Birth
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authorize Organization of Hope and (_____________) and its duly authorized agents to release to:
Name of Individual:
Title:
Organization:
Address: (Street City State Zip Code)
The following specific confidential information:
Psychological Reports/Diagnostic Information (Specify):
Medical/Medication Information (Specify):
Biopsychosocial History Information (Specify):
HIV-Related Information (Specify):
Alcohol and/or Drug Information (Specify):
Treatment and/or Transition Plan Information (Specify):
Other Information (Specify):
I understand the purpose of this release is __________
I understand that (Insert Organization’s Name)’s services are not contingent upon my decision to permitthe release of this information and I have consented freely, voluntarily, and without coercion, and that theabove information is accurate to the best of my knowledge. I understand that I have the right to revokethis authorization at any time except to the extent that action has already been taken to comply with it. Without my express revocation, this consent will expire on
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Person Served or Legal Representative
Date
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Witness
Date
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Mailing Address: P O Box 1466, Temple Hills, MD 20757 | Office: 1.855.9.OOHHOPE(1.855.966.4467)
Mobile: 1.443.653.8227 | 443.805.8927
E-mail: Info@OrganizationOfHope.org | Website: http://www.OrganizationOfHope.org
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