Client Limited Release Of Information Form printable pdf download

Template: Client Limited Release of Information Form

Created for adaptation by Julie Kunce Field, J.D. and NNEDV.

[APPROPRIATE AGENCY LETTERHEAD]

READ FIRST: Before you decide whether or not to let [Program/Agency Name] share some of your confidential

information with another agency or person, an advocate at [Program/Agency Name] will discuss with you all

alternatives and any potential risks and benefits that could result from sharing your confidential information. If you

decide you want [Program/Agency Name] to release some of your confidential information, you can use this form to

choose what is shared, how it's shared, with whom, and for how long.

I understand that [Program/Agency Name] has an obligation to keep my personal information, identifying information,

and my records confidential. I also understand that I can choose to allow [Program/Agency Name] to release some of

my personal information to certain individuals or agencies.

I, ___________________________, authorize [Program/Agency Name] to share the following specific information with:

name

Name:

W ho I want to

W ho

Specific Office at Agency:

have my

Phone Number:

information:

The information may be shared:

in person

by phone

by fax

by mail

by e-mail

I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people.

(List as specifically as possible, for example: name, dates of service, any documents).

W ha t i nf o about me

W ha t i nf o

will be shared:

(List as specifically as possible, for example: to receive benefits).

W hy I want my info

W hy

shared: (purpose)

Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your

confidential information held by [Program/Agency Name].

I understand:

That I do not have to sign a release form. I do not have to allow [Program/Agency Name] to share my information.

Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like

[Program/Agency Name] to release information about me in the future, I will need to sign another written, time-

limited release.

That releasing information about me could give another agency or person information about my location and would

confirm that I have been receiving services from [Program/Agency Name].

That [Program/Agency Name] and I may not be able to control what happens to my information once it has been

released to the above person or agency, and that the agency or person getting my information may be required by

law or practice to share it with others.

Expiration should meet the needs of the victim,

This release expires on

_____________

__________

which is typically no more than 15-30 days, but

Date

Time

may be shorter or longer.

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any

time either orally or in writing.

Date:______________

Signed:________________________

Time:______________

Witness:______________________

Reaffirmation and Extension

(if additional time is necessary to meet the purpose of this release)

I confirm that this release is still valid, and I would like to extend the release until ___________

___________

New Date

New Time

Signed:__________________________

Date:______________

Witness:_________________________

Client Limited Release Of Information Form

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