I,{applicantFirst} {applicantLast}, authorize St. Clair County Community Mental Health Authority's Office of Recipient Rights to disclose any reports/records regarding substantiated recipient rights violations to the party identified below for the purpose of verifying my eligibility for employment.
Further, I release St. Clair County Community Mental Health Authority, and its officers, agents, and employees from any and all claims, liability, and damages that may result from the release of said reports/records. In addition, I understand these reports/records may be provided to the Department of Licensing and Regulatory Affairs and Michigan Department of Health and Human Services, and I consent to the release of this information.