Release of Information ACCES

Dear Returning Consumer,

Each fiscal year, Taconic Resources for Independence, Inc.(TRI) needs to ask our returning consumers to update their files by signing the release of the "Authorization Pertaining To NYSED ACCES-VR." This form allows New York State Education Department's Office of Adult Career and Continuing Education Services ("ACCES-VR," formerly VESID) to review your file, so they know if we are following their guidelines in having all information on the consumers we serve. ACCES-VR 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 information.

By completing the enclosed authorization form, you can authorize or decline ACCES-VR’s access to your file. The choice is yours, and declining 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, except to the extent that the Independent Living program has already taken action based upon your existing authorization. To cancel this authorization after submission, please write to the IL Operations Director or Executive Director at TRI.

If the form is returned without a signature or the box is not checked off, it will not be considered valid. To avoid any confusion, please sign and confirm or decline the authorization. Thank you for your time in this matter.

Sincerely, .

Mandi Sheraden,
IL Operations Director

Attention: *Parents seeking Special Education Advoacy for their children under age 18 should not complete this form. There is a simular ACCES Authorization form specifically for Special Education Services.
RELEASE OF INFORMATION

AUTHORIZATION PERTAINING TO NYSED ACCES
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).

As an Independent Living Center, TRI receives funding from NYSED ACCES. NYSED ACCES has 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 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.
Consumer Name*

First NameLast Name
Date of Birth*

MonthDayYear
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*

(Yes) I hereby authorize TRI and/or its Representatives(No) 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
Consumer or Authorized Representative*

First NameLast Name
Description of Authorized Representative's Authority (Legal Guardian, etc.)
If you are the Consumer signing this form type "Self".
Date Signed

MonthDayYear
Date
Should be Empty:

Attention: *Parents seeking Special Education Advoacy for their children under age 18 should not complete this form. There is a simular ACCES Authorization form specifically for Special Education Services.

RELEASE OF INFORMATION