Coordinated Services Team Initiative (Cst) Page 4
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7SAMPLE FORM
This form is meant as a sample. Each county and tribe should develop their own form and
review it with partner agencies as well as appropriate legal counsel.
Coordinated Services Team Initiative
CONFIDENTIAL INTERAGENCY INFORMATION RELEASE AUTHORIZATION
Name:
Date of Birth:
Address:
Phone:
Complete the contact information below for each agency/individual that is authorized to release and obtain
information. Cross off (X out) any boxes that are left unused/blank.
All agencies/individuals listed below are hereby authorized to release and obtain information from all of the other
agencies/individuals listed below:
Agency/Individual:
Agency/Individual:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone #:
Phone #:
Fax #:
Fax #:
Agency/Individual:
Agency/Individual:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone #:
Phone #:
Fax #:
Fax #:
Agency/Individual:
Agency/Individual:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone #:
Phone #:
Fax #:
Fax #:
Agency/Individual:
Agency/Individual:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone #:
Phone #:
Fax #:
Fax #:
Agency/Individual:
Agency/Individual:
Address:
Address:
City, State, Zip:
City, State, Zip:
Phone #:
Phone #:
Fax #:
Fax #:
I, ______________________________________ hereby authorize all of the named individuals/agencies listed
above to release and/or obtain from any other of the above named individuals/agencies the following written and/or
verbal information/records, unless otherwise specified: mental health assessment and/or treatment; psychiatric
evaluation and/or treatment; psychological testing; medical and physical examinations and/or treatment; alcohol
and other drug abuse assessment and/or treatment; developmental disabilities assessment and/or case
management; Human/Social Service and/or Court records; educational testing, and school records,
Other___________________________.
The purpose or need for the information requested is ( ) Assessment and/or Treatment; ( )Case Management
Services; ( ) Interagency Coordination, Other______________________________________________.
Module 2
Page 21
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