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Bea Baxter Meyer


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I,__________________________________________________________________, authorize Roger N. Meyer of "…of a different mind" to exchange information with and receive information from:


Person and/or agency:_________________________________________________




Phone:_____________________________     FAX_________________ _________




The following checked items indicate information to be exchanged or released.  (Please strike out items not requested.)

____  Family History

____  Military Personnel records (non-medical)

____  Court records in possession of public authorities

____  Client/Attorney protected records

____  Social and family history

____  Complete educational/school records

____  Criminal records (background checks, police reports, parole or probation reports)

____  Employment history

____  Rental and housing history

____  Credit and personal finances history, including financial management/payee services

____  Vocational rehabilitation records

____  Other specify):__________________________________________________________


This authorization is valid while receiving services from Roger N. Meyer, and for ninety days following cessation of services and close of my case file, unless my consent is withdrawn, in writing, or unless a date is otherwise specified below.

                Date specified (if any):___________________________________________


I understand that by signing this completed form, I will allow the sharing of confidential information with the person and/or agency listed above.  With my written permission, this information may be redisclosed by Mr. Meyer to others, including Social Security Disability Determination Services and other benefits eligibility determination authorities.



Client signature(s)                                                                        Date



Client parent/guardian/legal representative signature           Date

   if client is a minor or otherwise not competent to authorize release.



Signature, Roger N. Meyer, DBA "..of a different mind"               Date



Release Form 2-05-05 OADM

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