AUTHORIZATION FOR RELEASE OF INFORMATION
I, being an applicant or client for financial assistance from Minnehaha/Lincoln County Department of Human Services and in order for them to develop an adequate record and file pertaining to my eligibility and suitability to qualify for services under the laws, rules, regulations and procedures of such agency, hereby authorize any individual or agency of any nature to release and furnish to the Minnehaha/Lincoln County Department of Human Services any information they have in their files regarding my physical, mental, academic, psychological, drug or alcohol abuse, social and economic condition. This information will be considered confidential information and shared only with institutions and agencies assisting with my financial needs.
This authorization shall be in effect for one year from this date, unless revoked by in writing at any time, except to the extent that action has already been taken to comply with it.
A copy of this release shall be as valid as the original.