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Release of Information

Individual Releasing Information

Birthday
Día
Mes
Año

The information that I agree to allow exchanged is the following:

Multi choice

The purpose for this exchange of information is:

The purpose for this exchange of information is:
Coordination of Care
Case Management/Service Coordination
Communication of Needs
Judicial Hearing(s) (Court)
Program Eligibility Determination
Other

Individual Completing Form

I am:

Single choice
The individual listed above
The parent of the individual listed above
The legal custodian, guardian, or conservator of the individual listed above

Releasing Information to PACT

I authorize PACT for Families to:

Multi choice

Who you are releasing the information from.

I understand that:

  • The information will be used for the purpose specified and will not be disclosed to other sources unless specifically authorized by law.


  • I may refuse to release this information and the consequences of refusal have been explained to me.


  • I may revoke this Authorization at any time by making a request in writing directly to the PACT for Families office; however, I understand that I cannot retroactively make such a revocation. Exception to revocation: To the extent that PACT for Families has already used or disclosed information under the Authorization or if the Authorization was obtained as a condition of obtaining insurance information.


  • The information to be exchanged will be treated as “private” or “confidential” as governed by the Minnesota Government Data Practices Act, M.S. 13.01 to M.S. 13.88.


  • This Authorization will permit two-way telephone or interactive television communication between the agencies or individuals listed.


  • This information may not be disclosed to anyone else other than those agencies or individuals listed above unless written permission is provided.


  • I am entitled to a copy of this authorization once I have signed it and I may review/request copies of information disclosed.

If I fail to specify an expiration date, event or condition, this authorization will expire in one year.

Unless otherwise revoked, this authorization will expire on:
Día
Mes
Año
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