I hereby authorize Iris Family Support Center to release information to and/or request
information from:
(i.e. DCS, Mustard Seed, GAL, CASA, housing, Township Trustee, Neighborhood Health Clinic, Etc.)
- Amani Family Services: 5104 N Clinton St., Fort Wayne, IN 46825 - 260-484-1414
- Children First Center: 1610 S Grandstaff Dr., Auburn, IN 46706 – 260-925-3865
- Lutheran Social Services: 333 East Lewis St, Fort Wayne, IN, 46802 – 260-426-3347
I understand that I may revoke this release in writing at any time except when information has
already been released because of this release.
Unless revoked, this release will remain in effect until the expiration time I have indicated
and initialed below.
I understand I have a right to privacy as protected under HIPAA regulations except where the
laws of the state of Indiana regarding child abuse and neglect
and the federal laws supersede this right.
Release is valid for no longer than 12 months. Expires on: