third party release-transfer authorization Instructions: If you would like us to be able to communicate with a third party and/or to receive and provide information to a third party (such as doctors, lawyers, ministers, family members, etc.), please read the following authorization statements and click the checkbox indicating you agree. Then fill out the form fields below indicating the contact information of the third party, and complete the digital signature information to finalize. Complete this form as many times as is necessary if you have multiple parties with whom you'd like us to communicate. NOTE: If there is no 3rd party with whom you wish us to be able to speak, please do not fill out this form.AUTHORIZATION(Required) I authorize Change, Inc. to discuss/disclose any and all case records (diagnosis, case notes, psychological reports, testing results, or other requested material) to the below listed third-party. I further authorize the third-party to discuss/disclose case records (diagnosis, case notes, psychological reports, testing results, or other requested material) to Change, Inc.. The purpose for this authorization includes (but is not limited to) a mutual exchange of information for the purposes of treatment at Change, Inc.. Treatment providers at either Change, Inc. or the third-party may discuss my case.I understand that I may revoke this consent at any time by providing written notice, and that this consent does not expire until I notify Change, Inc. in writing of my intention to revoke it. I have been informed that information will be given, its purpose, and who will receive it. I certify that I have read and agree to the conditions and have received a copy of this form.Would you like to provide any limitations or exceptions to the above statements to alter Change, Inc.'s ability to release(Required)YesNoLimitations/Exceptions Statement As an exception to the above Authorization, Change, Inc. is limited in its ability to release/may not release the items I have listed immediately below.Limitations/Exceptions(Required)Describe any limitations/exceptions with clarity.Third Party Name (with whom you'd like us to be able to share information)(Required) If you have more than one person you'd like us to be able to share information with, please complete this form as many times as needed. Third Party Address (with whom you'd like us to be able to share information)(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Third Party Phone Number (with whom you'd like us to be able to share information)AFFIXING OF NAME AS DIGITAL SIGNATURE / CONSENT(Required) By affixing my full name below as a digital signature, I consent to all of the above statements agree that Change, Inc. may receive and exchange information with the above-named party.Your Email(Required) Enter Email Confirm Email Address entered will receive a signed copy of this release. 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