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PSRS Release of Information Authorization Form

PSRS Release of Information Authorization Form

Use a PSRS Release Of Information Authorization Form template to make your document workflow more streamlined.

Following people or organizations as requested. Person/Organization 1 Primary Phone Work Phone Organization if applicable Relationship to Member Special Instructions This release is effective for a maximum of 24 months. Start Date REQUIRED End Date I hereby authorize PSRS/PEERS to release any personal information requested to the person or organization named above for a period no longer than 24 months beginning on the start date entered. PSRS/PEERS will not be held responsible for the release...
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