BCFH - Releasing & Obtaining Information Permission Form Logo
  • Releasing & Obtaining Information Permission Form

  • This information is entirely confidential

    To best serve your child and family, it may be necessary for BC Family Hearing Resource Society (BCFHRS) to obtain information from and share information with other professionals or agencies who are involved with your child. Information to be shared is limited to what is necessary to enable us to work effectively with you and your child (e.g. goals, observations, assessments, reports). This may be done in-person or using telephone, email, online video streaming applications, fax and/or mail. We take precautions to protect your privacy. However, you need to be aware that there is a risk of personal information being accidentally disclosed to other people.

    We need your permission to obtain and share information. This authorization will expire 12 months from the date of completion, or sooner at a family’s request.

    This agreement will be reviewed annually.

  • Please select all the options that you consent for us to use:

  • Which of the following professionals and/or agencies do you authorize BCFHRS to obtain information from and share information with? This may include past and current services as well as others you expect to start in the near future.

    Please indicate by checking the box. Please then provide as much information as you can for each professional/agency. If you do not know the name of the provider, please write “I do not know”. If you do not know their contact information, you can leave that space blank.

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  • By signing below, I give permission to BCFHRS to release and obtain verbal or written information to/from the above listed professionals and agencies:

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