Elevate Program Consent to Disclose Form - Catholic Charities of Baltimore

I*
First Middle Last
give permission for the release of any necessary medical, behavioral health, educational, social service, income or other pertinent information regarding myself to Elevate to assist in case managing, planning and assessing necessary supportive services. Elevate is also authorized to send any of the above information to outside agencies in order to assist in case managing, planning and assessing necessary supportive services. This information will be handled as confidential material. A photocopy of this authorization shall be as valid as the original.
This consent is effective from*
DD slash MM slash YYYY

(Period not to exceed one year)
Student Signature*
First Middle Last
Completion of this section becomes your official signature.
Date*
DD slash MM slash YYYY
Support Specialist Signature*
First Middle Last
Completion of this section becomes your official signature.
Date*
DD slash MM slash YYYY