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 information, which is retained by the Mercer County Board Of Social Services, may not be disclosed to another
person without my express written authority. I hereby give authority to the Mercer County Board of Social Services to disclose any
and all information regarding:
*Individual's Name (Print):__________________________________________________________
*Date of Birth:___________________________________________SS#:__________________________
To the following individual:
Senator Shirley K. Turner or her representatives Phone: 609-530-3277
15th legislative district representative Fax: 609-530-3292
1440 Pennington Road
Trenton, New Jersey 08618
This authorization expires on __________________________________________ or one year from the date signed, below, which ever is
less. I understand that upon this expiration date, the Mercer County Board of Social 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 Mercer County Board of Social 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 the Mercer County Board of Social Services
has taken action in reliance on this authorization. The written request to revoke this authorization must be provided to the Mercer
County Board of Social Services employee who received this Authorization. The revocation will be effective on the date that the
Mercer County Board of Social Services employee who received this Authorization receives the revocation.
My purpose in allowing the Mercer County Board of Social Services to disclose this information is as follows:
Receiving assistance
*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.