RELEASE of INFORMATION

 

1. I, ______________________________ (client), hereby authorize the Long-Term Recovery Committee of Southwest Indiana to release to all of its member agencies any information maintained by the Long-Term Recovery Committee of Southwest Indiana that is relevant for the purpose of providing assistance for my disaster-related needs caused by _________________________ (disaster) on _____________ (date).

 

2. I, ______________________________ (client), hereby authorize the agency listed below to release to the Long-Term Recovery Committee of Southwest Indiana any information maintained by said agency or person that is relevant and necessary for the purpose of providing assistance for my disaster-related needs caused by _________________________ (disaster) on _____________ (date).

 

3. I further understand that this Release of Information does not guarantee that assistance will be provided, but that without the information, my case cannot be presented for consideration.

 

Name of Agency and/or Person Designated:  ___________________________________

 

 

 

______________________________            ______________________________

Signature of Client                                          Signature of Spouse or Co-Client

 

 

 

____________________        ________        ____________________        ________

Identification*                         Date                Identification*                         Date

 

 

_________________________________

Pre-Disaster Address of Client

 

_________________________________      ____________________________________

City/State/Zip                                                  FEMA control number**

 

This release will end on _____________.

                                                date

 

*    Identification:  Driver's License, Utility bill or similar, pay stub – verify client identity and pre-disaster address.

** FEMA control number will very federal disaster assistance.

 

Source:  Casework in Disaster Response and Recovery handbook, The United Methodist Committee on Relief (UMCOR), Sample Interview Form #3, p. 92