I understand that giving consent to release information contained in my case file is strictly voluntary and will only be used by the designated agency/agencies to assist me in receiving appropriate services. I understand that I have the right to request that the disclosure of confidential information be limited to certain individuals. I understand that I have the right to revoke this authorization in writing at any time by sending notice to the Case Manager and/or Supervisor at Voices for a Second Chance.
I understand that this release of information is valid for a period of 30 days after the date of consent, unless I otherwise specify. I give permission for Voices for a Second Chance to release the following information.
- Basic identifying information (name, date of birth, social security number)
- Income and Employment Information (i.e. sources of income, job history, resume, education, testing scores and related information)
- Medical Information (medications, diagnosis, medical needs, tuberculosis test results, disabilities)
- Social Service Information (child protective services, adult protective services and related information)
- Assessments and reports (psychosocial assessments, psychiatric and psychological assessments, educational assessments)
- Substance Abuse History
- Criminal Background (conviction record, probation and parole information)
- Other (must provide in writing and submit as an attached document)
My signature verifies that this information has been explained to me and that my questions were answered to my satisfaction.