Client Release of Information Form | The Women's Advocacy Center

I authorize The Women’s Advocacy Center to share the following specific information with:

Who I want to have my information:

Name of Person*

First Last

Specific Agency*

This is the organization that you are approving us to share your information with.

Agency Phone Number*

The information may be shared:*

Select All
in person
by phone
by fax
by mail
by e-mail

Email Consent*

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

What information about me can be shared:

What info about me will be shared:*

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

Why I want my information shared: (purpose)

Why I want my info shared: (purpose)*

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

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 The Women’s Advocacy Center.

I understand:

Have to Sign Consent*

That I do not have to sign a release form. I do not have to allow The Women’s Advocacy Center 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 The Women’s Advocacy Center to release information about me in the future, I will need to sign another written, time-limited release.*

Other Agency Consent*

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 The Women’s Advocacy Center.*

Control Consent*

That The Women’s Advocacy Center 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.*

This release expires on Date*

Expiration should meet the needs of the client, which is typically no more than 15-30 days, but may be shorter or longer.

This release expires on Time*

:

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.

Signed*

Your signature indicates you have read all information in this form and verified its accuracy to the best of your ability to do so. Giving false or misleading information may result in termination of services and where applicable we may pursue prosecution for any damages suffered by The Women’s Advocacy Center. Please allow up to 48 hours to receive a response to your form submission. If you have not received a response within 48 hours, please send an email to: contactus@womensac.org.

Date*

Time*

: