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Old 04-07-2011, 07:21 AM
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Smile Authorization for Release of Information

Do any of you have a sample of an authorization for release of information form? The Center I work for would like to ask previous daycare providers about new clients payment history, etc. We have had several clients in the past year switching from provider to provider without making payments in full.

I felt this may help weed out some problems before they begin here.

Thank you for your help!
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Old 04-07-2011, 05:54 PM
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Michael Michael is offline
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Join Date: Aug 2007
Location: Moorpark CA, Ocean Ridge, FL
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Sorry this thread stayed in moderation for so long. Will this help:

Release of Information

You do not have to sign this, but it will help us get information we need to help you,
without having to get your signature on specific requests.

You should know that:
- We may need more information to decide if you can get assistance.
- If more information is needed from you, you will get a letter telling you what we need and the date you must get it to us.
- You are responsible to get the information or to ask us for help to get it.
- If you do not give us the information or ask for help by the due date, your application may be denied or your assistance may stop.
- We may be able to use the release below to get the information we need. But you still have to provide information we request or ask us for help.
- We may attach a copy of this release to a form that asks other people or organizations (like your employer) for specific information needed about you or others in your household.

Print and sign your name below to give us permission to get needed information.

I hereby authorize any person or organization to give ---------------------------------------- Services requested information about me or other members of my household.

A copy of this release is as valid as the original.

This release does not apply to protected health information.

This release is good for 12 months from the date signed.
Your Name (please print clearly)

Signature or Mark


Other Adult Name (please print clearly)

Mark Signature or Mark


Last edited by Michael; 04-07-2011 at 06:08 PM.
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Old 04-11-2011, 06:12 AM
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Smile Thank you!

Michael -

Thank you for the wording for the form I needed. I appreciate it and all that you do on this forum.
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