Authorization for Release of Information


  I authorize any of the following individuals to share and exchange information about my child with CAPE Head Start and for CAPE Head Start to share and exchange information about my child with these individuals or agencies. Any information received or shared will be used to evaluate and coordinate services for my child. I understand that this information is confidential and protected by federal law. I approve the release of this information and understand what this agreement means.

Child's Name: DOB:

Physician Name:

Address:

City: Zip Code:

Phone Number:


Dentist Name:

Address:

City: Zip Code:

Phone Number:

Use the fields below for other physicians, organizations, or individuals


Name: Title / Relationship:

Address:

City: Zip Code:

Phone Number:

Notes:


Name: Title / Relationship:

Address:

City: Zip Code:

Phone Number:

Notes:


These consents are valid until:

Leave this empty:

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Signature Certificate
Document name: Authorization for Release of Information
lock iconUnique Document ID: c9cef54e63a81cf94fca6d7bfd97512e41ff69c4
Timestamp Audit
April 14, 2021 10:20 am CDTAuthorization for Release of Information Uploaded by Joe Massaro - jmassaro@capeevansville.org IP 96.27.254.146