| Figure B-1 Sample Consent Form |
|---|
| Consent for the Release of Confidential Information |
| I, ___________________________, authorize XYZ Clinic to receive (name of client or participant) |
| from/disclose to ________________________________________ (name of person and organization) |
| for the purpose of _______________________________________ (need for disclosure) |
| the following information__________________________________ (nature of the disclosure) |
| I understand that my records are protected under the Federal and State Confidentiality
Regulations and cannot be disclosed without my written consent unless otherwise provided
for in the regulations. I also understand that I may revoke this consent at any time except
to the extent that action has been taken in reliance on it and that in any event this
consent expires automatically on ____________________ unless otherwise specified
below. (date, condition, or event) |
| Other expiration specifications: |
| _________________________ Date executed |
| _________________________ Signature of client |
| ________________________ Signature of parent or guardian, where required |
From: Appendix B --Protecting Clients' Privacy
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