Section IV. Who May Receive My Information
To whom y
ou would like the information sent:
______________________
_______________________________________________________________
Name
_____________________________________________________________________________________
Organization
_____________________________________________________________________________________
Address
_____________________________________________________________________________________
______________________
_______________________________________________________________
I understand that the person(s) or organization listed in this section may not be covered by federal or state
privacy laws, and that they may be able to further share the information that is given to them.
Sectio
n V. How Long This Permission Lasts
This
permission to share my information is good until ________________________________________.
[date or event]
If I
do not list a date or event, this permission will last for one year from the date it is signed.
• I understand that I can change my mind and cancel this permission at any time. To do this, I need to write
a letter to the Cannabis Control Commission, 101 Federal St., 13
th
Floor, Boston MA 02110, Attention:
Privacy Officer. If the information has already been given out, I understand that it is too late for me to
cancel the permission.
• I understand that if I choose not to give this permission or if I cancel my permission, I may still be able to
receive any services that I am entitled to, as long as this information is not needed to determine if I am
eligible for services or to pay for the services that I receive.
Section VI. Signature
Please sign and date this form and print your name.
___________________________________________ ________________________________
Your Signature Date
___________________________________________
Print Your Name
If this form is being filled out by someone who has the legal authority to act for you (such as the parent of
a minor child, a court-appointed guardian or executor, a custodial parent, or a health care agent), please:
Print the name of the person filling out this form: _________________________________________
