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Consent for Release of Information


Creative Housing requests the cooperation of Program Participants so we can best provide and sustain a safe, affordable, and inclusive living environment. Authorization granted is valid for only the duration of participation in Creative Housing programs and can be revoked by Participant in writing at any time.

Creative Housing works with authorized Contacts on behalf of Program Participants to ensure program requirements are met for stable, affordable housing. Consenting to authorization facilitates meeting program requirements and preventing the termination of housing benefits.



Participant Information


resides in a Creative Housing Home (CHH)
is a Private Market Rent Subsidy (PMRS) client

Service Coordinator


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Nisonger Specialist


 Not Applicable


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Provider - Primary


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Provider - Secondary


 Not Applicable


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Payee


 Not Applicable


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Other Money Management Support


 Not Applicable


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Advocate


 Not Applicable


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Advocate


 Not Applicable


 Authorization Granted

 Authorization Granted

 Authorization Granted

 Authorization Granted

Signature

  I consent to allow Creative Housing to communicate with the parties as authorized on this form for the purpose of meeting housing program requirements.


Signature


Signor is the Program Participant
Signor is the Guardian of the Person Estate for the Program Participant and their contact information is:


Guardian


Co-Guardian Contact Information