Redding Rancheria Community Services Authorization to Release of Information

Redding Rancheria Community Services Authorization to Release of Information
I, ________ (Name of Client) hereby request the disclosure of information from my record.

The information is to be released from:
Name of Client

First NameLast Name
Name of Facility
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Address
City/State
And is to be provided to:

Name of Person/Organization/Facility: Redding Rancheria Tribe

Address: 2000 Redding Rancheria Tribe

City/State: Redding CA 96001

The purpose or need for this disclosure is: Client & Billing Verification information to be released is from my (check all that apply)

__ Medical Record

__ Personnel Record

_X_ Other (Specify) _Energy Bill_ and includes (check as appropriate)

__ Entire Record

_X_ Only information related to (specify) _Energy Billing_

I understand that I may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. If this authorization has not been revoked, it will terminate one year from the date of my signature.
Signature
Date

MonthDayYear
Date
Should be Empty: