LIMITED RELEASE FORM

READ FIRST! Before you decide whether or not to let the East Texas Crisis Center, Inc. hereafter ETCC, share some of your confidential information with another agency or person, an advocate at ETCC will discuss all alternatives and any potential risks and benefits that could result from sharing your confidential information with you. If you decide you want ETCC to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.
  • I understand that ETCC has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow ETCC to release some of my personal information to certain individuals or agencies.
  • Name:Specific Office at AgencyPhone Number/Email 
    Add a new row
  • (List as specifically as possible, for example: name, dates of service, any documents).
  • (List as specifically as possible, for example: to receive benefits).
  • Please Note: There is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by ETCC
  • :
  • For ETCC OFFICE Use

    This release expires on _____/_____/_____ Time: ________ Expiration is typically no more than 15-30 days, but may be shorter or longer. Witness : _____________
  • I no longer give my permission to share the above personal information.
  • I confirm that I still give my permission to share the above personal information until: ______/_______/_______
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