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.)
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.