To: Applicants/ Referring Agencies From: Family Services, Inc. RE ...

AUTHORIZE FOR RELEASE OF INFORMATION
I HEREBY AUTHORIZE Family Services, Inc. to release information regarding my case
for the purpose of my financial management.
Client Name _____________________________
Account #: _____________________________
Release to: _____________________________
Information Granted: _____________________________
I HEREBY release the above named parties from any liability for revealing and releasing
such information. It is understood that this information, once obtained is not to be
released to any other company or individual.
_________________ ___________________________________
Date Signature of Client
_________________ ___________________________________
Date Family Services, Inc.
4925 Lacross Rd. Suite 215
North Charleston, SC 29406
Phone: 843-735-7820
Fax: 843-735-7821
Revised: 4/5/2012 11:13 AM