Dorchester County Health Department

Developmental Disabilities Administration

3 Cedar Street
Cambridge, MD 21613
Phone:  410-228-3223       Fax:   410-228-9319

AUTHORIZATION TO RELEASE OR OBTAIN INFORMATION

The undersigned hereby requests and authorizes that information to be provided:

(Specify the type of information and dates)

_________________________________________________________________________

_________________________________________________________________________

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Agency Requesting Information

Name: Dorchester County Health Department

Program: Developmental Disabilities Administration

Address: 3 Cedar Street - Cambridge , MD 21613

Phone: 410-376-0024

Agency Releasing Information:

Name: _________________________________________

Program: _______________________________________

Address: ________________________ City: ________________ State: _____ Zip: _______

Phone: ___________________

Conditions for exchange of authorized information:

I understand that I may revoke my consent to release information from my records, but not retroactive to release of information already made in good faith. This consent will expire one year from date unless otherwise specified.

Witness: ______________________________________

Signed (Client):_________________________________

Date: _________________________________________

Signature of parent, legal guardian or personal representative (specify).

This is a: (check one)

Re-disclosure or recopying of this record information by the recipient (s) is prohibited, except when implicit in the purposes of this disclosure.