Client Release Confidential Info Date I, Client Name * DOB * Hereby authorize Doctor's Name * to release the following confidential information about me: Checkboxes Physical Exam or Office Visit with 12 months that includes-Problem List and Medications. For the purpose of: to determine eligibility for Adult Foster Care services. This information will not be given, sold, transferred or relayed to any other person not specified in this consent form, without first obtaining my written consent, which states the need for the proposed new use of this information or the need for its transfer to another person. Signature of Client or Guardian * signature keyboard Clear *The client or guardian has the right to withdraw consent at any time. Submit If you are human, leave this field blank. Δ
