Authorization for Release of Information s3

H OME C ARE Management Corporation

Authorization for Release of Information

I hereby authorize all of my former employers to release to HOMECARE Management Corporation all information regarding my employment with them, including my position, responsibilities, and job performance. I understand that this information then may be released to agencies with which HOMECARE Management Corporation has contracts when requested in conjunction with my working with clients of that agency.

I release from all liability the company and persons releasing this information, and I release HOMECARE Management Corporation from all liability for any damages from the disclosure of this information.

A photocopy or facsimile of this release of information shall have the same force as an original.

Printed/Typed Name______

Signed ______Date ______