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Authorization for the Release and/or Discussion of Protected Health Information


I hereby authorize: WE CAN to contact the following organization:

To obtain the following information:


Permission about Specific Information and Privacy.

Please check the boxes below, as appropriate, and write your initials below. 


Reason for sharing this information.

This information may be used only for the purpose of: 

I understand I have the right to see this information at any time.


Any information already released may be used as stated on the consent.


I understand the requested or provided information is needed to determine  and coordinate my services.


If you do not list a date or event, this permission will last for one year from the date it is signed.

You may change your mind and cancel this permission at any time, by writing a letter to the Assistant Director at WE CAN.


By my signature below, I affirm that I have read this release or it has been read to me, and I understand its content.

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