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Consent to Exchange Information 

authorize Patty’s Hope and

to disclose and exchange my confidential information. I understand that the purpose of this disclosure is to determine eligibility and/or assist with coordinating services.
This authorization expires 12 months from the signing of this document, or when Patty’s Hope is no longer providing me with services.
By entering my name or signature, or mark, on the “Authorizing Signature” line below I am signing this document and affirm that the information entered in this document are true and that I agree to the terms outlined in this document.
Authorizers Name:
Authorizing Signature:
Witness Name (if required):
Witness Position:
Witness Signature:

Consent to Exchange Information - Individual                                                                                Page 1 | 1



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