Authorization to Release Information for Victims of Domestic Violence, Dating Violence, Sexual Assault or Stalking

Before you authorize a program to share any of your confidential information with another agency or person, program staff will discuss potential risks and benefits of sharing your confidential information. If you decide you want the program to release some of your confidential information, you can use this form to choose what is shared, how it is shared, with whom, and for how long.

Confidentiality Protections for Information Related to Domestic Violence, Dating Violence, Sexual Assault, and Stalking

I understand that [WRITE PROGRAM NAME] has an obligation to keep my personal information, identifying information, and my records related to domestic violence, dating violence, sexual assault, or stalking confidential.  This information is not entered into any shared database and is kept in a separate case file from my normal case file. [WRITE PROGRAM NAME] must not disclose, reveal, or release any personally identifying information or individual information about domestic violence, dating violence, sexual assault, or stalking, regardless of whether the information has been encoded, names have been redacted, or the information is otherwise protected. 

I understand that I can choose to allow [WRITE PROGRAM NAME] to release my personal information related to domestic violence, dating violence, sexual assault, or stalking to the individuals and agencies I specify, in the form I specify, and for the period of time I identify.  I understand that I do not have to sign this release form in order to obtain services from [WRITE PROGRAM NAME] and that signing this release is completely voluntary.  In the alternative, I can choose to allow [WRITE PROGRAM NAME] to release my other personal information, excluding my personal information related to domestic violence, dating violence, sexual assault, or stalking.

If release of information is compelled by statutory or court mandate, [WRITE PROGRAM NAME] shall make reasonable efforts to notify me and shall take steps necessary to protect my privacy and safety.

Authorization to Disclose Information

I, [WRITE YOUR NAME], born on [WRITE YOUR D.O.B.], authorize [WRITE PROGRAM NAME] to share the information specified below with:

Name: [WRITE NAME OF PERSON]

Agency/Organization Name: [WRITE NAME OF AGENCY OR ORGANIZATION]

Contact Information: [WRITE CONTACT INFORMATION]

 

The information may be shared:

[CHECK ALL THAT APPLY]      

in person

by phone

by fax

by mail

by e-mail (I understand that e-mail is not a highly secure form of communication and may be subject to “hacking” or other forms of interception by unauthorized persons.  Initial here to authorize use of e-mail to share information: [WRITE INITIALS]

 

I authorize the following information to be released:

[CHECK ALL THAT APPLY AND ALSO DESCRIBE EACH]

Documents, limited to:

Dates of service:

Type(s) of service, limited to:

Other, limited to:

The purpose of this disclosure is limited to:

 

I understand that releasing this information about me could give another agency or person information about my location and would confirm that I have been receiving services from [WRITE PROGRAM NAME].  I understand that [WRITE PROGRAM NAME] 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.

Expiration: This release expires on: [WRITE DATE].  If no date is entered, this release will expired 30 days from the date it was signed below.

Signature: [YOU SIGN HERE]

Date: [WRITE DATE]

Witness:  [WITNESS SIGNS HERE]

Date: [WRITE DATE]

Certificate of Translation

I, [WRITE NAME OF PROGRAM STAFF], certify that [WRITE YOUR NAME] is not a person with limited English proficiency, or that the client declined interpretation services offered.

I, [WRITE INTERPRETER NAME], certify that on [WRITE DATE], I translated this document from English to [WRITE LANGUAGE] for [WRITE YOUR NAME], and that the client signed it after discussing it with [WRITE PROGRAM NAME] staff.  I certify that I shall not disclose any communications made by the client or [WRITE PROGRAM NAME] staff nor shall I share any information I have obtained while acting in my capacity as an interpreter.

Interpreter Signature: [INTERPRETER SIGNS HERE]  

Date: [WRITE DATE]

 

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