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.
  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • 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.
  • Information Authorized for Release (select all that apply)*

  • 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.
  • Date Signed (Client)*
     - -
  • Are you signing as a client representative?*

  • Representative Information (if applicable)

    Complete this section only if you are signing as a representative.
  • Date Signed (Representative)
     - -

  • RAD Supportive Living Use Only

    For internal use by RAD Supportive Living staff.
  • Date Received
     - -
  • Should be Empty: