Release of Information ACCES Parents

Dear Returning Parent,

Each fiscal year, Taconic Resources for Independence, Inc. (TRI) needs to ask our returning consumers to update their files by signing the release forms in the links below. This form allows the New York State Education Department's Office of Adult Career and Continuing Education Services (ACCES-VR), the Office of Children & Family Services (OCFS), and the Office of Persons With Developmental Disabilities-Family Support Services (OPWDD-FSS) to review your child's file, so they know if we are following each of their guidelines in the provision of services. The funding sources may or may not audit consumers' files each year, but when they are in our office, we want to be proactive and prepared concerning your child's information.

Completing the authorization form on the next page allows you to authorize or decline the funding sources' access to your child's file. The choice is yours, and refusing the authorization does not deny you the right to any services here at TRI. You have the right to change your decision year to year, and you still have the right to revoke it at any time. Please write to TRI's Contract Compliance and Database Manager or Executive Director to cancel this authorization after submission.

You must submit this form with a signature and select a check-off box to be considered valid. To avoid any confusion, please sign and confirm or decline the authorization. Thank you for your time in this matter.

Sincerely,

Patrick Muller, M.S.W.
Contract Compliance and Database Manager

RELEASE OF INFORMATION

AUTHORIZATION PERTAINING TO NYSED ACCES, DUTCHESS COUNTY OFFICE OF CHILDREN AND FAMILY SERVICES (OCFS), OFFICE OF PERSONS WITH DEVELOPMENTAL DISABILITIES - FAMILY SUPPORT SERVICES (OPWDD-FSS)
By signing this form, you authorize Taconic Resources for Independence, Inc. (TRI) to allow the review of your consumer file and protected health information by the New York State Education Department's Office of Adult Career and Continuing Education Services ("ACCES," formerly VESID), Dutchess County Office of Children and Family Services (OCFS) and Office of Persons with Developmental Disabilities - Family Support Services (OPWDD - FSS).

The Special Education Program at the Independent Living Center, receives funding from NYSED ACCES, DC OCFS and OPWDD - FSS. These funders have the obligation to monitor that our services meet certain eligibility criteria and standards pursuant to state and Federal law. The information reviewed will only be used for the purposes, set forth below, and will only be used and shared by authorized ACCES, OCFS and FSS staff.

You have a right to decline this authorization. Your services, the payment for your services, and your health care benefits will not be affected if you choose to decline. If you sign this form, you will have the right to revoke it at any time, except to the extent that the Independent Living program has already taken action based upon your authorization. To revoke this authorization, please write to the Program Manager of the Independent Living program in which you participate.
Child's Name:*

First NameMiddle Name or InitialLast Name
Child Date of Birth*

MonthDayYear
Parent/Guardian's Name:*

First NameLast Name
USE AND DISCLOSURE COVERED BY THIS AUTHORIZATION

We understand that information about you and your health is personal, and we are committed to protecting the privacy of that information. A representative of TRI must answer these questions completely before providing this authorization form to you. DO NOT SIGN A BLANK FORM.
Please Check for Authorization or Declination*

I hereby authorize TRI and/or its Representatives:I decline to give authorization to TRI and/or its Representatives:

...To submit my file for REVIEW ONLY by the agency, individual, or employer identified below: Name/Title or Organization:

NYSED ACCES	DC OCFS	OPWDD-FSS
89 Washington Avenue, EBA 5th	60 Market Street	38 Fireman’s Way
Albany, N.Y. 12234	Poughkeepsie, NY 12601	Poughkeepsie, NY 12603
(518) 474-2925	(845)486-3662	(845)473-5050
Fax: (518) 473-6073	FAX:(845)486-3090	FAX:(845)473-7198

What information will be reviewed?

The following information: Entire contents within your file for the purpose of monitoring, by NYSED ACCES, DC OCFS and OPWDD - FSS, of TRI's compliance with the eligibility requirements for ILCs and compliance with the CIL (Centers for Independent Living) Standards, including the following: Date of Birth ; Gender; Race/Ethnicity (if provided) ; Employment and Education status; County where you reside; Veteran status and Disability information Required documents, such as Consumer Rights and Responsibilities, Consumer Grievance, Individual Authorizations (Consents) and Documentation of Services will also be reviewed.

* Please note: Information within your file will only be reviewed and no contents of your file shall be removed, nor will any copies be made for this NYSED ACCES, DC OCFS, and OPWDD -

What is the purpose of this review?

Monitoring, by NYSED ACCES, DC OCFS and OPWDD - FSS of TRI's compliance with the eligibility requirements for ILCs and compliance with the CIL (Centers for Independent Living) Standards as identified above.

When will this authorization expire?

This authorization shall remain in effect for one year beyond the date it is signed unless you revoke it in writing.
I have read this form and all of my questions about this form have been answered.*

Clear
Signature of Consumer or Authorized Representative
Parent/Guardian's Name:*

First NameLast Name
Date Signed*

MonthDayYear
Description of Authorized Representative's Authority (Legal Guardian, etc.)*
We encourage you to Review your Release of Information Form for accuracy by clicking the Review, Print and Save PDF button below. Then you can click on the mini printer icon and for Destination either Print to your local printer on the list or choose to Save as a PDF and save a copy on your computer. Then come back to this page and hit Submit to proceed to Step 4, Welcome Letter.
Should be Empty:

RELEASE OF INFORMATION