AUTHORIZATION TO RELEASE INFORMATION I, the undersigned, voluntarily authorize Thrive Transitional Housing to disclose and/or receive limited information about me to/from the individual or organization listed below.

Title / Relationship (e.g., Case Manager, Probation Officer, Treatment Provider, Family Member): *

Email and Phone Number *

PURPOSE OF DISCLOSURE This information is being shared for the following purpose(s): *

TYPE OF INFORMATION TO BE RELEASED *

NOTE: This authorization does not permit the release of medical records, mental health treatment records, or detailed clinical information unless specifically required and allowed by law.

I understand that:

Thrive Transitional Housing is a recovery residence and follows OKARR (Oklahoma Alliance for Recovery Residences) standards for confidentiality and resident rights.
My information will only be shared for the purposes listed above and only with the person or organization named in this form.
This authorization is voluntary and I may refuse to sign without affecting my ability to apply for or remain in the program, unless disclosure is required by law or court order.
Information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by confidentiality laws.

EXPIRATION & REVOCATION : This authorization will expire on: *

Signature *