Please provide contact information (name and phone or email) for two (2) people not residing with you, in the event we cannot reach you:
If you answered Yes to receiving government assistance:
If you served in the U. S. Military
CONSENT TO EXCHANGE INFORMATION
I understand that different agencies provide different services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.
I authorize the following confidential information about the above customer(except drug or alcohol abuse diagnoses or treatment information) to be exchanged:
I can withdraw this consent at any time by telling the referring agency. This will stop the listed agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about me has been shared, and why, when, and with whom it was shared. If I ask, each agency will show me this information. If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they need.