Washington Consent Form 2003

DSHS cannot refuse you benefits if you do not sign this form unless your consent is needed to determine your eligibility. I may revoke or withdraw this consent at any time in writing but that will not affect any information already shared. I understand that records shared under this consent may no longer be protected under the laws that apply to DSHS. A copy of this form is valid to give my permission to share records. CONSENT NOTICE TO CLIENTS The Department of Social and Health Services DSHS can help you better if we are able to work with other agencies and professionals that know you and your family. By signing this form you are giving permission for DSHS and the agencies and individuals listed below to use and share confidential information about you. DSHS 14-012 X REV. 02/2003 INSTRUCTIONS FOR COMPLETION OF CONSENT FORM Purpose Use this form when you need consent to use confidential information on a continuing basis about a client within DSHS or to disclose that information to other agencies to coordinate services or for treatment payment or agency operations or for other purposes recognized by law. If you have questions about how DSHS shares client confidential information or your privacy rights please consult the DSHS Notice of Privacy Practices or ask the person giving you this form. CLIENT IDENTIFICATION NAME DATE OF BIRTH ADDRESS IDENTIFICATION NUMBER CITY TELEPHONE NUMBER INCLUDE AREA CODE STATE ZIP CODE OTHER INFORMATION I consent to the use of confidential information about me within DSHS to plan provide and coordinate services treatment payments and benefits for me or for other purposes authorized by law. - Understanding Be sure the client understands what permission is being granted and how and why information will be shared. If needed use a translated form and interpreter or read the form aloud. If the client needs more information provide an additional copy of the DSHS Notice of Privacy Practices or refer the client to the public disclosure officer for your unit - Client Have client or a child over age of consent 13 for mental health and drug and alcohol services 14 for HIV/AIDS and other STDs any age for birth control and abortions 18 for health care and other records sign this box and insert the date of signature. If the client needs more information provide an additional copy of the DSHS Notice of Privacy Practices or refer the client to the public disclosure officer for your unit - Client Have client or a child over age of consent 13 for mental health and drug and alcohol services 14 for HIV/AIDS and other STDs any age for birth control and abortions 18 for health care and other records sign this box and insert the date of signature. The client may substitute a mark in this box that you witness. - Agency Contact or Witness You will sign in this box if you are the one presenting and explaining the form to the client. - Other Include in this box any additional information that may help to locate records that may include parts of DSHS involved with services names of family members or other relevant information. CONSENT AUTHORIZATION - Agencies or persons exchanging records The client s completion of this form allows the use and sharing of confidential information within all of DSHS. DSHS will be able to disclose to and receive confidential information from the outside agencies or persons listed. Provide identifying information about the agencies or providers including name address or location if possible.