Section 2-800 - Authorization for Release of Information

CMH EMS Education Manual

I authorize a member of CMH EMS Education Department to release the following information to the authorized persons listed.

Note: This authorization expires one year after the date below.

List of persons authorized to recieve above information:

Name Agency or relation

Print name:

Signature:

Date:

Change Log:

DateLink to
previous
version		Description of change
08/17/16Added this section.
07/17/19Changed document number from 4-940 to 2-800
08/21/20pdfMoved this section to the online format.

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