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Consent to Exchange Information 
 
I,                                                                                         , authorize Patty’s Hope and the Department of Social Services to disclose and exchange my confidential information. I understand that the purpose of this disclosure is to determine eligibility for Patty’s Hope services.
This authorization expires on                                                         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:
Date:
Witness Name (if required):
Witness Position:
Witness Signature:
Date:

Consent to Exchange Information - DSS                                                                                       Page 1 | 1

11/15/2021

Sent