Directions: print this form, complete it, and fax it to (609) 530-3292 or mail it to 1440 Pennington
Road, Trenton, NJ 08618
AUTHORIZATION TO DISCLOSE INFORMATION
I understand that my personal information may not be disclosed to another person without my expressed written authority. I
hereby give authority to the Department of Human Services and its representatives to disclose any and all information regarding:
*Individual's Name (Print):__________________________________________________________
*Date of Birth:___________________________________________SS#:__________________________
To the following individual:
Senator Shirley Turner or her representatives
15th Legislative District
1440 Pennington Road
Trenton, NJ 08618
Phone: (609)530-3277
Fax: (609)530-3292
This authorization expires on ______________________________ or one year from the date signed, below, which ever is less.
I understand that upon this expiration date, the Department of Human Services will no longer provide my information to the
person stated above, and that if I wish for this person to continue to receive information, I must execute another authorization.
I understand that if the above-named person is not a health care provider or part of a health plan covered by federal privacy
regulations, my health information may be re-disclosed by the person I have named above and will no longer be protected by
these regulations. However, the person named above may be prohibited from disclosing substance abuse information under the
Federal Substance Abuse Confidentiality Requirements.
I understand that if I refuse to sign this form, the Department of Human Services will not disclose my information to the person
named above.
I understand I may revoke this authorization at any time, in writing, except to the extent that the Department of Human Services
has taken action in reliance on this authorization. The written request to revoke this authorization must be provided to the
Department of Human Services employee who received this Authorization. The revocation will be effective on the date that the
Department of Human Services employee who received this Authorization receives the revocation.
*Signature (or mark) of Individual, Parent of Minor Child, Legal Guardian or Attorney-in-Fact:
____________________________________________________________________________
*Date of Signature: ____________________________*Telephone Number: _______________________________
Name of Parent of Minor Child, Legal Guardian or Attorney-in-Fact (if applicable):
____________________________________________________________________________
Copy of Valid Appointment of Guardianship or Power of Attorney must be attached.
If a mark is provided in place of a signature, above, the mark must be witnessed:
Witness Signature (if applicable):__________________________________________________
Witness Name/Title:_____________________________________________________________
*Denotes information that is required.