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Child and Family Agency

Child and Family Agency

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Forms – Release of Information and assignment of benefits for insurance companies


Release of Information and Assignment of Benefits for Insurance Companies

Client Name(Required)
MM slash DD slash YYYY
Person Financially Responsible(Required)
Policy holder's name(Required)
MM slash DD slash YYYY
Add a secondary insurance company?(Required)
Secondary Insurance Policy holder's name(Required)
MM slash DD slash YYYY
Add a tertiary insurance company?(Required)
Tertiary Insurance Policy holder's name(Required)
MM slash DD slash YYYY





Address of Policy holder(Required)





Authorization of release of information(Required)
MM slash DD slash YYYY
Authorization of payment(Required)
MM slash DD slash YYYY
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