Release of Information Consent (Social Services)

Captures specific information to be shared, recipients, purpose, and expiration date for time-limited consent. Used by case managers to comply with 42 CFR Part 2, HIPAA, and VAWA confidentiality requirements.

Client Information

• Client Full Legal Name
• Date of Birth
  Used to verify identity and match records. Not stored beyond case file.
• Client / Case ID Number
  Enter your agency-assigned client or case number if available.
• Client Phone Number
• Client Email Address
• Preferred Contact Method
  Select how you prefer to be contacted regarding this consent.

Disclosing Organization

• Disclosing Agency / Program Name
• Program Type
  Select the program type to determine applicable confidentiality rules.
• If 'Other', describe the program type
• Case Manager / Staff Name

Receiving Party (Recipient)

• Recipient Name (Individual or Organization)
• Recipient Organization / Agency
• Recipient Mailing Address
• Recipient Phone Number
• Recipient Fax Number
  Required if information will be transmitted by fax.
• Recipient Email Address
• Method of Transmission
  Select all methods by which information may be transmitted to the recipient.

Information to Be Released

• Categories of Information to Be Released
  Select each category of record to be released. Do not select categories not needed for the stated purpose.
• Describe 'Other' records to be released
• Records From Date
  Earliest date of records to be included. Leave blank if all records are authorized.
• Records Through Date
  Latest date of records to be included.
• Additional Specifics or Limitations on Records
  Note any exclusions or further restrictions on what may be shared.

Purpose of Disclosure

• Primary Purpose of Disclosure
• Describe the Specific Purpose
  Provide a clear, specific statement of why this information is being shared.
• Does VAWA Confidentiality Apply to This Client?
  VAWA (34 U.S.C. § 12291(b)(2)) prohibits disclosure of personally identifying information without informed, written, reasonably time-limited consent.
• VAWA Confidentiality Notice
  VAWA Notice: If VAWA applies, this consent must be voluntary, informed, and time-limited. The client may not be denied services for refusing to sign. Staff may not share any information that could identify the client as a survivor without this signed consent.
• 42 CFR Part 2 Notice
  42 CFR Part 2 Notice: Substance use treatment records are protected by federal law. Recipients may not re-disclose these records without a separate written consent from the client, except as permitted by 42 CFR Part 2.

Consent Duration and Expiration

• How Should This Consent Expire?
• Expiration Date
  Consent will automatically expire on this date. Maximum recommended duration is 12 months.
• Expiration Event or Condition
• Right to Revoke
  You have the right to revoke this consent at any time before its expiration by submitting a written revocation to your case manager. Revocation does not apply to disclosures already made in good faith before the revocation was received. Refusing or revoking consent will not affect your eligibility for services.

Client Acknowledgment and Signature

• Was an interpreter used to explain this form?
• Language Interpreted
• Client is Signing As
• Legal Representative / Guardian Name
• Relationship to Client
• Client or Authorized Representative Signature
  Sign to authorize the release of information as described above.
• Date Signed
• Witnessing Staff Member Name
  Name of agency staff who witnessed the signing.
• Witnessing Staff Signature
• Copy of Signed Consent Provided to Client?
  Clients must be offered a copy of this signed consent per HIPAA §164.520.