I understand by signing this form that I am requesting information to be sent/released to the third party I have indicated above. I understand I may revoke this authorization at any time with written notification. I realize that Viverant cannot prevent re-disclosure of records as a result of this request; therefore, Viverant is released from any and all liability resulting from re-disclosure. I have read and understand my rights.
(expires one year from date above unless earlier date indicated)
Contact us today to get started.
877-609-0123 or 952-835-4512