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: