Perinatal Cluster
Complete this consent on screen, then print it to sign. A signature is required to authorize the release of information. Also available in Spanish.
I authorize the following agencies and/or organizations to exchange information regarding case history, psychological and educational assessments, treatment, and progress updates in order to develop comprehensive service coordination goals that meet the needs of this client and/or family. Information released may be subject to re-disclosure. The agencies below have my permission to exchange/share information while assisting me through the Perinatal Services Council. If there are exclusions, please indicate.
I understand that I may revoke my consent to release information at any time. This consent form is valid for one year from the date it is signed or as otherwise stated.
Revocation of consent
Sign below only if you wish to revoke your consent. Upon revocation, further release of specified information shall cease immediately.
