Client Consent & Authorization Form

Client Consent & Authorization Form

Please complete this form to authorize RAD Supportive Living to receive and use your information for housing and supportive services coordination.
Client Information

Please provide your personal information below.
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Current Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Consent for Release of Information

By completing this section, you authorize RAD Supportive Living to receive, review, and use information related to your housing needs, eligibility, and supportive service coordination for the purposes of determining suitability for placement and participation in the program. This includes the exchange of information between RAD Supportive Living and the referring agency or organization.
Referring Agency/Organization*
Authorized Contact Person*
Identification informationHousing historyIncome or benefit verificationCase management or support informationDischarge or transition planning informationOther (please specify)
Purpose of Disclosure
HIPAA Acknowledgment and Authorization Expiration

Your information may include protected health information (PHI) as defined by HIPAA. Information will be shared only with individuals directly involved in your referral or placement. You may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken. This authorization will expire 90 days from the date signed unless revoked earlier.
Client Signature*

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Date Signed (Client)*

MonthDayYear
Date
No, I am the clientYes, I am a representative
Representative Information (if applicable)

Complete this section only if you are signing as a representative.
Representative Name
Relationship to Client
Representative Signature

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Date Signed (Representative)

MonthDayYear
Date
RAD Supportive Living Use Only

For internal use by RAD Supportive Living staff.
Date Received

MonthDayYear
Date
Reviewed By
Notes
Should be Empty:

Client Consent & Authorization Form

Client Information

Consent for Release of Information

HIPAA Acknowledgment and Authorization Expiration

Representative Information (if applicable)

RAD Supportive Living Use Only