Form — Release of Information | YWCA West Central Michigan

Email *

I understand that the YWCA West Central Michigan has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow the YWCA West Central Michigan to release some of my personal information to certain individuals or agencies.

I, __________(name below)________________(____date of birth below______)_, authorize the YWCA to share the following specific information with:

Your Name *

First Last

Date of Birth *

Who I Want to Have My Information

Name

First Last

Specific Office at Agency/Address:

Phone *

Fax

The Information May Be Shared: *

in person
by phone
by fax
by mail
by e-mail (only when required)

*I understand that electronic mail (e-mail)may not be confidential and can be intercepted and read by other people.

What info about me or my children (note name and dob for children included in the release) will be shared: *

(List as specifically as possible, for example: name, dates of service, any documents).

Why I want this info shared: (purpose) *

(List as specifically as possible, for example: to receive benefits).

Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by the YWCA.

I understand:

• That I do not have to sign a release form. I do not have to allow the YWCA to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like the YWCA to release information about me in the future, I will need to sign another written, time-limited release.

• That releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from the YWCA.

• That the YWCA and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others.

This release expires on:

Expiration will meet the needs of the client, which is typically no more than 15-30 days, but no longer than 90 day is allowed.

I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing.

Signature *

Date *

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Form — Release of Information

Who I Want to Have My Information