CONSENT FOR RELEASE OF INFORMATION
TO: _______________________________________________
I, _______________________________________, born __________________, Social Security Number ___________________, hereby authorize and direct you, to: 
(1) 	communicate with _______________________________ (Releasee) about my situation, 
(2) 	answer all of Releasee's questions about same, and 
(3)	send copies of all documents pertaining to me requested by Releasee in your possession to Releasee at _____________ _____________________________________________.  
The purpose of this disclosure is for Releasee to __________ ________________________________________.    I understand the information being disclosed may otherwise be subject to redisclosure and may no longer be protected under the regulations.
I understand that my records are protected under federal confidentiality regulations and cannot be disclosed without my written consent unless otherwise provided for in the regulations.  I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc.) and that in any event this consent expires at the earlier of ____________, or 180 days from now.
Executed this _______ day of ________, 20___.

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