A 501(c)(3) Non-Profit Organization | Georgia, United States
info@onramp-independence.org | (555) 123-4567

Form ORI-ROI-01
Rev. 2025

Authorization to Release / Exchange Information

Complete this form to authorize OnRamp To Independence to share or receive your confidential information with a designated third party.

Your Rights: You have the right to revoke this authorization at any time by notifying OnRamp To Independence in writing. Revocation does not apply to information already released in good faith prior to receipt of the revocation. Signing this form is voluntary and will not affect your access to services.

1. Client Information

Client Full Name *

Date of Birth *

Client ID (if known)

Phone

2. Direction of Information Exchange

This authorization is for OnRamp To Independence to: *

Release information TO the party listed in Section 3 Receive information FROM the party listed in Section 3 Exchange (both release and receive) with the party in Section 3

3. Third Party (Sending or Receiving Information)

Organization / Agency Name *

Contact Person

Address

Phone

Fax

4. Information to Be Released / Received

Records from Date

Records through Date

Or: All records on file

Yes, all records

Specific Records or Additional Description (optional)

5. Purpose of Release

Why is this information being shared? *

Coordination of services Referral to another program Case management / planning Legal proceeding Insurance / benefits verification Research / evaluation (de-identified) At client's request Other: _________________________

6. Expiration of Authorization

This authorization expires: *

On a specific date: ___________________ Upon a specific event: ___________________ One (1) year from date of signature Upon completion of the referral or service listed above

7. Notice of Rights & Acknowledgment

Right to Revoke: I understand I may revoke this authorization at any time by submitting a written request to OnRamp To Independence at info@onramp-independence.org or by mail to our office. Revocation will not apply to information already disclosed in reliance on this authorization.

Voluntary Participation: I understand that signing this form is entirely voluntary. Refusing to sign will not affect my ability to receive services from OnRamp To Independence, unless the information is specifically required to provide those services, in which case I will be notified.

Re-Disclosure: I understand that once my information is released to the third party named above, OnRamp To Independence cannot control how that party uses or re-discloses the information, except to the extent required by law.

Copies: I am entitled to receive a copy of this signed authorization upon request.

8. Signature

Signature of Client (or Authorized Representative) *

Date *

If signing as authorized representative, name and relationship to client

Authority (e.g., Parent, Guardian, POA)

CONFIDENTIAL — OnRamp To Independence Client Record