Release of Information

Individual Releasing Information

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

The purpose for this exchange of information is:

Individual Completing Form

I am:

Releasing Information to PACT

I authorize PACT for Families to:

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.