Consent Disclose West Lincoln Community Care Consent to Disclose Information Client Information: Name: Address: Phone Number: Email Address: Service Provider: Account Number (if applicable): Consent: I grant my consent to West Lincoln Community Care to share with the above stated service provider, mycontact, account and billing information for the purpose of determining eligibility and making payment for services. I also grant my consent to my service provider to use and disclose my personal information for these purposes. I declare the information that I have given, to the best of my knowledge, is true and correct. Signature of person giving consent: SIGNATURE Date: Applicant Signature ×
