Third Party Record Request and Release

Third Party Record Request and Release

  1. Montgomery County Office of Children and Youth
  2. Third Party Record Request and Release
  3. I,
  4. hereby authorize
  5. to request and receive my Montgomery County Children and Youth records. 

    I understand these records contain confidential information, and I am waiving that confidentiality below.

    By allowing a 3rd party (PERSON RECEIVING THE RECORDS) to request and receive records on my behalf, I am waiving the confidentiality of my Children and Youth records. I understand these records may contain information regarding drug and alcohol treatment, mental health treatment, and other protected information. I am authorizing that information to be released to the Company/Person listed below.

  6. Enter your Initials authorizing that information to be released to the Company/Person listed below.

  7. This release is valid for 1 year from the date signed below.
     If you wish to cancel this release, please send a letter or email revoking the authorization to:
    Montgomery County Children and Youth
    C/O Dionna Sanders, P.O. Box 311
     Norristown, PA 19403

  8. Electronic Signature*
  9. Leave This Blank:

  10. This field is not part of the form submission.