I hereby give my consent for the release of information contained on my application to be released or discussed with other agencies or service providers for the sole purpose of referrals and billing inquires only. By this consent, I shall hold Welfare Reform Liaison Project, Inc. harmless for any liability that I may incur as a result of any disclosure made within the bounds of my consent and authorization.
I understand that my records are protected under 10A NCAC 97B.0302 CONFIDENTIALITY AND DISCLOSURE OF INFORMATION and cannot be disclosed without my written consent unless otherwise provided for in the regulations. The only exception to this requirement is if the disclosure is required by court order or for program monitoring by the Office, authorized federal, state, or local monitoring agencies. I understand that this CONSENT is voluntary, and can be withdrawn/revoked at any time except to the extent that action has been taken in reliance on it, and that in any event, this consent expires automatically as follows:
One year from the date of Consent, unless otherwise specified.