Release of Information

I do hereby authorize West Georgia Star to release and/or receive information from the following agencies:

Georgia Department of Labor
Troup County Department of Family and Children Service
Troup County Health Department
Salvation Army
Emmanus House
Harmony House
The Ark Refuge
Fellowship Deliverance Outreach Ministry
Pathways Center
Troup County Juvenile Court
Troup Diversion Center
Southern Crescent
Doctor/Medical Center
Relative(s)
Other (Please Specify)

Resident Name

First Name

Last Name

Resident Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date of Birth

YYYY

Signature

I understand that the purpose of this release of information is to allow West Georgia Star service coordinator(s) to share and receive information with the above mentioned agencies in order to provide assistance, intervention and continuity of services for the resident named above. Furthermore, I understand that all information released to or received from the above agencies will be held in strictest confidence.

I agree