Broome County Office for Aging Release of Information Revocation 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your full name in the designated field. Ensure you print your First Name, Middle Initial, and Last Name clearly.
3. Review the statement regarding the revocation of permission for the Office for Aging staff to access your personal information. Make sure you understand its implications.
4. Sign and date the form at the bottom where indicated. If a legal representative is completing this on your behalf, ensure they attach any necessary legal documentation.
5. Fill in your address, date of birth, and phone number in the specified fields to provide complete contact information.
6. Once all fields are completed, submit the signed form to Broome County Office for Aging at the provided address.

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