Clinical Release of Information

READ FIRST: Before you decide whether or not to let SARC share some of your confidential information with another agency or person, an advocate at SARC will discuss with you all alternatives and any potential risks and benefits that could result from sharing your confidential information. If you decide you want SARC to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.

I understand that SARC has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow SARC to release some of my personal information to certain individuals or agencies.

I authorize Sarc to share the following specific information with the following person(s):

Name(s)

Specific Office or Agency and address:

Phone number or email where they can be reached:

The information may be shared (please select appropriate boxes)

What info about me will be shared: List as specifically as possible, for example: name, dates of service, any documents

Why I want my info shared. 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 SARC.

I understand: That I do not have to sign a release form. I do not have to allow SARC to share my information. Signing a release form is completely voluntary. That this release is limited to what is written above. If I would like SARC to release information about me in the future, I will need to sign another written, time-limited release. 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 SARC. That SARC 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:

Month/Day/Year

Expiration should meet the needs of the victim, which is typically no more than 15 - 30 days, but may be shorter or longer. Can be up to 1 year.

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.

Name*

First NameLast Name

Signature*

Date*

Date