IRAD Consent Form

IRAD Consent Form

AUTHORITY TO EXCHANGE AND RECEIVE INFORMATION
CLIENT/PARTICIPANT DETAILS
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CONSENT AND SIGNATURE

I consent to the use of my personal information being shared with:
- Parties involved in the service delivery associated with my program (E.g. Plan Coordinators, Treaters, Doctors, Parents/ Carers, Insurers, Doctors and other professionals or services).
- With any person you request or permit us to keep informed of our services as they relate to you.
- To comply with any regulations that apply to us and the services that we provide to you.
- I understand that only personal and health information related to my disability/injury and other factors affecting my possible engagement in services will be collected and/or shared.
Client/Participant Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
GUARDIAN/PARENT CONSENT

I am authorised to act on behalf of the person named above and have read and understood thePrivacy Policy. I consent on behalf of the person named above for the use of his/ her/ their personal information being shared as set out above.
Name

First NameLast Name
Signature

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Date

MonthDayYear
Date
Relationship to client/participant
Phone Number
Please enter a valid phone number.
Should be Empty:

CLIENT/PARTICIPANT DETAILS