Case Manager Release Form

Name(Required)

I hereby grant my permission for BANGORHOUSING, to release confidential information and material to the below named agency’s person.

Case Manager/Other Contact(Required)

Company Name

Address

Address Line 2

Office Phone Number

Cell Phone Number

Fax Number

Email Address(Required)

My signature on this release also allows the above-named agency’s person to release any confidential information and material to BANGORHOUSING.

I understand that no such information or material will be released without this specific permission except where provided by law. I also understand that I have the right to review copies of any information or material released and to revoke this permission in writing at any time.

Date(Required)

Signature(Required)