Authorization for Release of Information

Name *

Household members (If applicable):

This Release will include any of the following items that are checked: * Check All
Financial Information
Medical Information
Progress Notes
Utility Information
Mental Health Information
Housing Information
Family History
Treatment Plans
Current/Previous Employment
Other

If you would like the Community Navigator to coordinate with specific people or organizations (such as family members, case managers, medical providers, or agencies), please list their names here.

Acknowledgment and Consent: * I authorize the above information to be released to or obtained from the Community Navigator, including but not limited to partner agencies, service providers, and organizations involved in my care or support
I understand that the information shared under this release may be confidential in nature. I may revoke this authorization at any time by notifying the Community Navigator in person, by phone, mail, or email.
I understand that this authorization expires 1 year from the submission date

By checking this box, I agree that my electronic signature is the legal equivalent of my handwritten signature. I understand that this authorization form is being signed electronically and that my electronic signature is valid and enforceable under Maine law. I understand that I may request a paper copy of this form or choose not to sign electronically. I also understand that I may withdraw my consent to use an electronic signature before submitting this form.

Electronic Signature Consent * I consent to use an electronic signature