Instructions:
Submitting this
form authorizes 4People and the
Agency
to remove
personal information collected about you or your family with
other non-profit, governmental, and volunteer organizations
participating in the 4People Case Management Network.
Should you wish a
copy of your records and those caseworkers that have viewed
or provided input please authorize
Agency
to produce these
records for you.
I, Client (First & Last) Name:
Phone:
Address:
Date of Birth:
City: State:
Zip:
E-Mail:
SSN:
hereby
authorize the Agency listed in the block above to remove any
of my information in its possession
with other non-profit, governmental, and volunteer
organizations participating in the 4People Case Management
Network in order to coordinate services and
assistance.
If you wish to
limit this revocation to specific information, please specify
the information that may be revoked.
Limitations to this revocation:
I understand that such information will be removed provided
enough identifying information (name, birthdate, and SSN)
was supplied above to identify my records in the 4people
system.
By agreeing and submitting this
form, having read the above or had it read to me, I
understand the terms and conditions. I have also had the
opportunity to ask any questions. Additionally, I am signing
this revocation on behalf of my children that are under the age
of eighteen (18)
(First & Last) Name Head of Household
Name of Spouse
Name of Child #1
Age
Name of Child #2
Age
Name of Child #3
Age
Name of Child #4
Age
Name of Child #5
Age
Name of Child #6
Age
I Agree constitutes signature
I do
not Agree
Once you submit this agreement a preview screen will come
up. If all of the information is correct, please print and
place in client's file BEFORE pressing SUBMIT.