PRINCE GEORGE’S COUNTY
COVID-19 EMERGENCY RENTAL ASSISTANCE PROGRAM
Page 1
Client Information Authorization
Prince George's County, Maryland
I, ___________________ , hereby authorize the owner/landlord or its agent to exchange any information
concerning my history, and/or that of my immediate family, care, treatment, household demographic, housing
issues, income ,assets or benefits between directors, agencies, and staff to the Prince George’s County
Department of Housing and Community Development, Department of Social Services, and/or its partners. The
purpose of this release is to protect my privacy, help staff make referrals and to help me or my family receive
better planning and delivery of services.
I understand that the aforementioned information will be communicated to other agencies using this computer
system in several ways. One of which will include communication through a computer-based online system.
The highest level of security measures is taken to protect the online system. Only authorized personnel will be
able to view my personal information.
I understand that the System Administrator, the Prince George's County Department of Social Services, the
Office of Housing and Homeless Service, and the Prince George’s County Department of Housing and
Community Development have personnel authorized to view my personal information.
Basic demographic information and information about services offered is entered into the Service Point Client
Profile. The information will be shared with all agencies that participate in the Service Point System in Prince
George's County.
This release authorizes a free exchange of information between agencies for a period not exceeding three years
in order to give the most complete and thorough services available. I understand that I may revoke this
authorization at any time.
_____________________________
Print Name:
_____________________________ __________________
Signature Date
_____________________________ __________________
Signature of parent, guardian, or authorized representative, when required Date
I
understand that my records are protected under federal regulations and cannot be disclosed without my
written consent or as otherwise permitted by such regulations, and that in any event this consent expires
three years from the date of entry or upon my departure from further service provider participation.
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