Electronic Release of Information

  • Authorization to Disclose Confidential Information

    I, hereby voluntarily authorize the use and disclosure of protected health information (“PHI”) and other information deemed relevant to Delaware County Adult Court Services (“ACS”) about me by signing this Authorization to Use and Disclose Protected Health Information Form (“Authorization”). This Authorization applies to the following individual, identified below by name, date of birth (“DOB”), and social security number, and authorizes the use and disclosure as specified herein:
  • Agency Name:Address:Phone Number:Contact Name (If known) 
  • Written revocation must be submitted to the following person at the ACS

    Delaware County Adult Court Services, Joseph N. Perry, Chief Probation Officer 117 North Union Street, Delaware, Ohio 43015
  • FirstLastDate of BirthSocial Security Number