Release of Information Authorization

In order to provide services to you True Friends needs to obtain information from, or share information with other individuals, programs, or providers. True Friends needs information to provide you services. If True Friends does not receive this requested information, or if we cannot share with others who work with you, True Friends will not be able to provide you the services you may need or True Friend’s assistance may be hindered. Additionally True Friends needs this authorization to be following government laws and/or regulations.

Participant name______

Participant date of birth______

Program name:True Friends

I, (name of person or person’s legal representative) ______request and authorize True Friends to receive and disclose information needed to provide services to the participant from the following people/agency(ies):

  1. The participant
  2. The participant’s legal representative
  3. Case manager and other county personnel
  4. Department of Health and Human Services
  5. Residential providers
  6. Medical personnel, including primary doctor, psychologist, psychiatrist
  7. Other support services

for the purpose of providing continuity of services. Information requested includes health diagnosis, personal information, current service plans, etc.

I know that state and federal privacy laws protect my records. I know:

  1. Why I am being asked to release this information.
  2. I do not have to consent to the release of this information. Opting out will affect True Friend’s ability to provide needed services to me.
  3. If I do not consent, the information will not be released unless the law otherwise allows it.
  4. I may stop this consent with a written notice at any time, but this written retraction will not affect information True Friends has already released.
  5. The person or agency(ies) who receive my information may be able to pass it on to others.
  6. If my information is passed on to others by True Friends, it will no longer be protected by this authorization.
  7. This consent will end one year from the date I sign it, unless the law allows for a longer period.

This consent expires on (one year from current date)______

Name / Signature / Title / Date
Person
Legal representative

Release of Information Authorization 12-2013