Get Choices For Care Permission For Release Of Information - Division Of ... - Ddas Vermont

Filling out the Choices for Care Permission for Release of Information form is an important step in facilitating your eligibility for the Choices for Care program. This guide provides clear, step-by-step instructions to help you fill out the form online accurately and efficiently.

Follow the steps to complete the form online.

1. Click ‘Get Form’ button to access the form and open it in the designated online platform.
2. Begin by printing your name clearly in the space provided at the top of the form. Ensure that the name matches the name on your Choices for Care application.
3. Provide your permission by filling in the specific individuals and entities with whom you agree to share your information. This includes the Department of Disabilities, Aging and Independent Living (DAIL) Long-Term Care Clinical Coordinator, your legal representative, the local Waiver team, and Choices for Care program providers.
4. List any family members, friends, or other pertinent contacts in the space provided. Make sure to include full names and any relevant organizations, such as a physician, mental health agency, or housing provider.
5. If applicable, write any individualized instructions regarding the release of your information. Be clear and concise in this section to ensure your intentions are understood.
6. Read the confidentiality statement carefully. It’s important to understand that your information will be respected as confidential and used solely for the purposes stated.
7. Sign the form where indicated, acknowledging that you have read and agree to the terms outlined in the document.
8. Fill in the date of signing next to your signature. Ensure this is the current date for accurate record-keeping.
9. Indicate the expiration date for your consent to share information; this should not exceed one year from the date signed.
10. Once you have completed all fields, review the form for accuracy and completeness before finalizing.
11. After verifying your information, save changes, download a copy of the form, print it for your records, or share it with the necessary parties as required.

Complete your Choices for Care Permission for Release of Information form online today to ensure your needs are met effectively.