How do I submit the Authorization for Release of Information?

Submit it to the department named on the form. Check the county website for current contact details.

What information does this form ask for?

It asks for client details, the name and address of the recipient, the information to be obtained or released, the purpose, an expiration period or condition if different from twelve months, and signatures and dates.

Can I revoke this authorization?

The form says you may revoke the authorization at any time in writing, except to the extent action has already been taken in reliance on it.

Chemung County, NY · Chemung County

No notary required

Authorization for Release of Information

This form lets a client authorize Chemung County Department of Human Services to obtain or release specified information to a named person or organization.

At a glance

Issued by: City of Chemung County · Chemung County, Chemung County, New York
Notarization: Not required: file this form without a notary.
Official source: chemungcountyny.gov
Blank form: Download the PDF
Catalogued: Oct 5, 2026
Machine-readable: JSON record · about the forms index

What this form is

Clients use this form to authorize the Chemung County Department of Human Services to obtain information from or release information to a named organization, agency, or person. It asks for client details, the recipient, information categories, and the purpose of disclosure, along with signatures and dates. The authorization expires after twelve months unless a different period, event, or condition is specified.

Who needs it

A client who wants to authorize the department to obtain or disclose specified information to a named person or organization needs this form.

How to submit it

Submit it to the city department named on the form; check the city website for current contact details.

About notarization

This document is signed without a notary; the client and any applicable representative and witness sign and date it, and no notarized attachment is stated.

How to submit this form

1
Download the Form
Download the Authorization for Release of Information.
2
Complete Client Details
Enter the client's name, address, gender, town or city, and date of birth.
3
Identify Information and Purpose
Name the recipient, select the information to obtain or release, and indicate the purpose.
4
Sign and Date
The client and any applicable parent, guardian, personal representative, and witness sign and date the form.
5
Submit to the Department
Submit the completed form to the department named on the form; check the county website for current contact details.

Frequently asked questions

Do I need a notary for the Authorization for Release of Information?: No. This document is signed without a notary. The client and any applicable representative and witness sign and date it; the form does not identify a notarized attachment.
How do I submit the Authorization for Release of Information?: Submit it to the department named on the form. Check the county website for current contact details.
What information does this form ask for?: It asks for client details, the name and address of the recipient, the information to be obtained or released, the purpose, an expiration period or condition if different from twelve months, and signatures and dates.
Can I revoke this authorization?: The form says you may revoke the authorization at any time in writing, except to the extent action has already been taken in reliance on it.

Need something notarized?

This Authorization for Release of Information doesn’t need a notary, but if you have another Chemung County form that does, a commissioned online notary can help.