Get Village Network Consent For Release Of Confidential Information 2020-2025

Completing the Village Network Consent For Release Of Confidential Information is essential for individuals seeking to authorize the release of their confidential information. This guide will provide you with clear and supportive instructions to navigate the online form effectively.

Follow the steps to fill out the form accurately and securely.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Enter your full name in the 'Client name' field, followed by your date of birth in the specified section to ensure accurate identification.
3. Provide your Social Security Number in the corresponding field and include any other legal names you may have used previously.
4. In the 'I authorize' section, fill in the name and address of the organization you are authorizing to release information.
5. Specify the individuals or organizations from whom you wish to obtain or exchange information in the respective fields.
6. Choose the types of information you wish to release by checking the relevant boxes, including Treatment Summary, Diagnostic Assessment, and others as necessary.
7. Indicate the time frame for the requested information and ensure you are only including the minimum necessary items to fulfill the purpose.
8. Clearly state the purpose for which this information is being released in the designated area.
9. Review the consent terms to ensure you understand the implications of releasing your confidential information.
10. If applicable, specify a particular expiration date for the consent if you do not want it to last for the default period of 180 days.
11. Provide your initials and sign the document in the section provided. If you are not the client, include your relationship to the client.
12. Complete the staff facilitator's section by including the printed name and signature along with the date.
13. Save your changes, download or print the completed form as needed, or share it securely with the necessary parties.

Complete your consent form online today to ensure your information is handled properly.