Lassenlinks ROI

Consent for Release of Information & Authorization to refer to Community Resources

In order to provide better services to you and your family, this program would like your permission to connect you with other community resources that may be available to you. By signing this consent form, you allow us to provide you with the best possible service by sharing your information with the Lassen County Home Visiting Collaborative.
Servicing Agency Information
Name of Program
Name of Representative from Program
Email of Program Representative
example@example.com
Client Information
Name

First NameMiddle InitialLast Name
Email of Client
example@example.com
Address
City
State
Zip
Date of Birth

MonthDayYear
Date
Phone Number
Please enter a valid phone number.
Legal Status

Minor with Parent or legal guardianWard of Juvenile Court
Does parent retain educational rights?

YesOther
I authorize the following programs to share my information so that I can receive better service:
Organization Names (Please check the programs you authorize)

Lassen County Office of EducationPublic Health DepartmentLassen WORKSLassen Oral Health ProgramPathways to Child & Family ExcellenceSierra Cascade Family OpportunitiesWomen Infant ChildWrap AroundLassen InterventionLassen Wellness CenterNortheastern Rural Health ClinicsLassen Indian Health CenterAcorns to Oak TreesLassen Union High SchoolOther
You will know in advance when we are making a referral on your behalf. Our program will only voluntarily release your name, phone number, address, and family needs/family plan to the community partners named above. Medical information, financial information and social history are only released toproviders who are directly linked to those services. To protect your confidentiality, your information will not be shared with non-essential persons and will be stored in a secure area.
Purpose/Limitation of requested use or disclosure (initial)

Client RequestContinuum of CareLimitationOther
Please describe limitations/other if initiated
This authorization shall remain effective until the date below or until revoked in writing prior to that date (not to exceed two years).

MonthDayYear
Date
I understand I have a right to receive a copy of this authorization upon request. A digital version has been sent to me if an email address has been provided above. A photocopy of this authorization is as valid as the original. I understand I have the right to revoke this authorization. I understand if I revoke this authorization, I may do so in writing and submit it to the following address, or I may request assistance where I receive services:

Ronda Hall

1445 Paul Bunyan Rd, Susanville, CA 96130

RHall@co.lassen.ca.us
I understand the revocation will not apply to information already released based on this authorization. If I have authorized the disclosure of my health information to someone who is not legally required to keep it confidential, I understand it may be re-disclosed and no longer protected, but any alcohol and/or drug treatment records cannot be re-disclosed without my written consent unless otherwise provided for by 42 CFR Part 2 and 45 CFR parts 160 and 164. I understand authorizing the disclosure of this health information is voluntary. I can refuse to sign this authorization. I do not need to sign this form to assure treatment or payment, enrollment, or eligibility for benefits. I understand I may inspect or obtain a copy of the information to be used or disclosed. I have the right to receive a copy of this authorization.
I hereby authorize the use and disclosure of my information in accordance with the information entered above for the purposes described in this form. I understand this does not authorize the recipient of this disclosed information to further use or disclose this information, except as allowed or required by law. I further understand information released then becomes the responsibility of the recipient and is no longer under the protection of the releasing entity.
Print Name
Signature of Parent or Guardian

Clear
Date

MonthDayYear
Date
Witness
Title/Department
Date

MonthDayYear
Date
Should be Empty:

Consent for Release of Information & Authorization to refer to Community Resources

Servicing Agency Information

Client Information