Consent to Exchange Application

Consent to Exchange Information

I understand that different agencies provide different services and benefits. Each agency must have specific information in order to provide services and benefits. By signing this form, I am allowing agencies to exchange certain information so they work together effectively to provide or coordinate these services or benefits.

Client Name

Last 4 Digits of SSN

Other

I consent that the following information can be exchanged. Check the documents you consent to be shared with partnering agencies:

Other/Additional Information

I want this information to be exchanged only for the following purpose(s):

Service Coordination

Treatment Planning

Eligibility Determination

Follow-up

Other (specify below):

Other

I want information to be shared: (check all that apply):

Written Information

Meetings (in-person and virtual)

Phone

Computerized Data

Other (specify below):

Other

This Consent is Good Until:

I can withdraw this consent at any time by telling the referring agency. My withdrawal will stop the listed agencies from sharing information after they know my consent has been withdrawn. I have the right to know what information about me has been shared, as well as why, when, and with whom it was shared.

If I ask, each agency will show me this information.

I want all the agencies to accept a copy of this form as a valid consent to share information. If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they need.

Participant First Name

Participant Last Name

Particpant is under 18

Yes

Electronic Signature

Date

Relationship to the client:

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