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54 Section IV: Duties Relating to Right of Subjects <br />• [IDENTITY OF AGENCY/ENTITY] <br />CONSENT FOR RELEASE OF INFORMATION <br />We are asking for your consent (permission) to release information about you to the entities or <br />persons listed on this form. The information can't be released without your consent. This form <br />tells you what information we want to release, or what information we want another entity to <br />release to us. This form tells you the reasons we are asking for your consent. You have the right <br />to look at all the information to be released and have copies of it. You should do this before you <br />give your consent to release the information. If you want to look at the information or have <br />copies of it, you must talk to (NAME AND HOW TO CONTACT). <br />You may consent to release all of the information, some of the information or none of the <br />information. You may consent to release information to all, some, or none of the entities listed <br />on this form. <br />If you give us your consent, we can release the information for (TIME PERIOD) or until EVENT OR <br />CONDITION). You may stop your consent any time before (THIS TIME PERIOD EVENT OR <br />CONDITION). If you want to stop your consent, you must write to (NAME AND ADDRESS OF <br />PERSON and clearly say that you want to stop all or part of your consent. Stopping your consent <br />will not affect information that already has been released because you gave your consent. <br />You do not have to consent to the release of any information that tells people that you or your <br />child is disabled. If you are asking for help because of a disability, we may need information <br />about the disability in order to help you. <br />If you have a question about anything on this form, please talk to (NAME) before you <br />sign it . <br />[A.] I authorize the [entity] to release information about [name of data subject]. I understand <br />that: <br />[B.] The information I agree to let you release is: <br />[C.] The information will be given to: <br />[D.] You are asking me to release this information so that: <br />[E.] If this information is released, what will happen is: <br />[F.] If this information is not released, what will happen is: <br />[G.] Signature of client <br />[H.] Signature of parent or guardian <br />[I.] Signature of person explaining this form <br />and my rights <br />Date signed. <br />Date signed <br />Date signed <br />Date signed <br />July, 2000 Model Policy: Access to Government Data & Rights of Subjects Data <br />