Personal Information Consent Form

PERSONAL INFORMATION CONSENT FORM

Client Name:    Date of Birth:

Purpose of Collection and Use

I authorize the organization named above to collect, use and disclose my personal information for the following purpose(s). The scope of consent is limited to the purpose(s) I select below and the disclosures described in this form.

Select purpose(s) (check all that apply): Case management, support services, or care coordination
Administrative processing, billing, or eligibility verification
Program evaluation or aggregate research (de-identified unless otherwise authorized)
Other - specify:

Types of Personal Information to be Collected

The organization may collect the following categories of personal information as reasonably necessary for the purposes selected. Check each category you authorize.

Identification information (name, date of birth, address)
Contact information (phone number, email)
Health-related information or medical records
Financial information necessary for billing or benefits (bank or account information excluded unless checked below)
Sensitive identifiers (social security number, passport number) — collect only if required
Other:

Disclosure and Recipients

I consent to the disclosure of my personal information to third parties when necessary to accomplish the purpose(s) selected above. Examples include, but are not limited to, partner service providers, insurers, legal counsel, and government agencies when required by law.

Service providers engaged by the organization
Insurers, payors, or benefits administrators
Family members or personal representatives designated by me
Legal advisors, auditors, or compliance personnel
Other - specify recipients:

Duration, Renewal, and Withdrawal of Consent

This consent is effective from Effective Date until Expiration Date or until withdrawn in writing by me, whichever occurs first. Withdrawal will not affect disclosures already made in reliance on this consent prior to receipt of written revocation, nor will it negate obligations required by law.

Effective Date:    Expiration Date (or enter 'ongoing'):

To withdraw consent, contact:   Phone:

Security, Storage, and Retention

The organization will store personal information using reasonable administrative, technical, and physical safeguards appropriate to the sensitivity of the information. Information will be retained only as long as necessary to fulfill the purposes described above or as required by law, after which records will be securely destroyed or de-identified.

Consequences of Refusal or Withdrawal

If I refuse or withdraw consent, the organization may be unable to provide certain services, process claims, or perform administrative tasks. The organization will inform me of specific consequences that relate to the service or benefit in question prior to relying on refusal or withdrawal.

Rights of the Individual

I understand that I have the right to request access to my personal information, request correction of inaccurate information, and request information about disclosures made under this consent. Requests should be submitted in writing to the contact person listed above. The organization may require reasonable verification of identity before fulfilling a request.

Acknowledgment and Certification

By signing below I certify that: (a) I have read and understand this Personal Information Consent Form; (b) I have had an opportunity to ask questions and received answers to my satisfaction; (c) I voluntarily consent to the collection, use and disclosure of my personal information as described above; and (d) I understand how to withdraw consent and the effects of withdrawal.

I authorize the organization to contact me for follow-up regarding services and program evaluation.
I authorize limited re-contact for future related services, where permitted by law.

Record of Consent (to be completed by organization representative, if required)

Representative Name:    Title/Role:

Method of verification of identity (describe government ID, records reviewed, or means of verification):

Sign Now