Authorization To Release Information - Pcg Public Partnerships

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Client Name: ________________________
Client Medicaid ID: ________________________
Public Partnerships - Colorado, Inc. (PPC)
Authorization to Release Information Form
I. Disclosure Information
Organization authorized to provide the information: Public Partherships-Colorado, Inc.
I hereby authorize the use or dislosure of my individually identifiable protected information which may
include health information as described below. I understand that this authorization is voluntary and that I
may revoke it at any time by submitting my revocation in writing to PPC.
II. Designated Representative Information
Name of individual to whom PPC, Inc is authorized to disclose information:
___________________________________________________________________________
Phone number of designated representative: (_______) ____________ - _____________
Relationship to Client:_________________________________________________________
Information that can be used or disclosed:
• Employee / Attendant Information
• Authorization, Budget and Payroll Information
Health Information
Other
1
Authorization to Release Information-Version 2.0, Rev 9-2015

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