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Run: Release of Information Consent (Social Services)

This Release of Information Consent (Social Services) template captures exactly what can be shared, who can receive it, why it is being released, and when co...

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Client Information

Client Full Legal Name (required)

Date of Birth (required)

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 (required)

Program Type (required)

Select the program type to determine applicable confidentiality rules.

If 'Other', describe the program type

Case Manager / Staff Name (required)

Receiving Party (Recipient)

Recipient Name (Individual or Organization) (required)

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 (required)

Select all methods by which information may be transmitted to the recipient.

Information to Be Released

Categories of Information to Be Released (required)

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 (required)

Describe the Specific Purpose (required)

Provide a clear, specific statement of why this information is being shared.

Does VAWA Confidentiality Apply to This Client? (required)

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? (required)

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? (required)

Language Interpreted

Client is Signing As (required)

Legal Representative / Guardian Name

Relationship to Client

Client or Authorized Representative Signature (required)

Sign to authorize the release of information as described above.

Date Signed (required)

Witnessing Staff Member Name (required)

Name of agency staff who witnessed the signing.

Witnessing Staff Signature (required)

Copy of Signed Consent Provided to Client? (required)

Clients must be offered a copy of this signed consent per HIPAA §164.520.

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