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It defines the purpose of information sharing to support service delivery, including coordination and case management, and lists authorized information categories (e.g., medical, education, mental health, HIV-related, housing, drug/alcohol). The form explains consent validity, expiration, rights to revoke or amend, access to a signed copy, privacy law references, potential redisclosure limits, and revocation instructions, including signature, witness, and role options for participants or legal guardians.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/authorization-for-release-disclosure-and-exchange-of-information-revised-july-2020/290047/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/authorization-for-release-disclosure-and-exchange-of-information-revised-july-2020/290047.png","ImageObject",442,249,{"name":88,"@type":89},"Lucas Martin","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-09-23","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",6,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information categories can be authorized for release and exchange?","Question",{"text":109,"@type":110},"The form allows authorization for categories such as Medical, Education, Drug/Alcohol, Mental Health, HIV-Related, and Housing, along with Limited Release and an Other option.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"How long is the authorization valid?",{"text":114,"@type":110},"Consent and authorization expire no later than one year from the date below unless the participant revokes it in writing prior to that time.",{"name":116,"@type":107,"acceptedAnswer":117},"Can the participant or guardian revoke the authorization?",{"text":118,"@type":110},"Yes. 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This limited release means that the referring agency will only share basic information about the participant and the type of issue for which the participant seeks referrals. The participant can then choose to share more information, or sign an unlimited release after they become a client with the new agency.  \nMy consent and authorization to this mutual disclosure and exchange of information and records is being granted with the following understandings on my part:  \n• That this consent and authorization is not valid without the required signature below;  \n• That my consent and authorization is being provided voluntarily, and that it will expire no later than one year from the date below unless I revoke it in writing prior to that time;  \n• That I have the right to revoke or modify this authorization at any time in writing, except to the extent that information may have already been disclosed pursuant to this consent and authorization;  \n• That I have the right to request a copy of this form after I sign it, and may have the right to inspect or copy any information shared or disclosed in accordance with this consent and authorization to the extent allowed for by state and federal law;  \n• That I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment from at least certain of the providers outlined above. I also understand, however, that there may be consequences attendant to a decision on my part to not authorize the disclosure and sharing of information, i.e., that at least some of the organizations listed above may not be able to effectively provide services without it;  \n• That some of the information shared between the organizations listed above may be subject to various state and federal privacy laws, including but not limited to HIPAA, FERPA and/or the alcohol and drug abuse privacy regulations (42 C.F.R. Part 2), and that all of the organizations listed above agree to comply with those regulations to the extent they apply to their respective activities, including but not limited to any restrictions or allowances for the any further disclosure of information shared or provided to them in accordance with this consent and authorization;  \n• That when certain types of my information are used or disclosed pursuant to this authorization, they may be subject to redisclosure by the recipient to others without my knowledge or further authorization, in which event applicable privacy laws may no longer protect my information;  \n• That, to the extent I am authorizing the disclosure of information above that specifically relates to alcohol or drug abuse, t","cbCaiooThXrwl2T0","https://ap.wps.com/l/cbCaiooThXrwl2T0","pdf",271943,"English","# Authorization for Release, Disclosure and Exchange of Information\n## Authorized Information Types\n## Consent Understandings and Expiration\n## Revocation of Authorization / Consent","[{\"question\":\"What information categories can be authorized for release and exchange?\",\"answer\":\"The form allows authorization for categories such as Medical, Education, Drug/Alcohol, Mental Health, HIV-Related, and Housing, along with Limited Release and an Other option.\"},{\"question\":\"How long is the authorization valid?\",\"answer\":\"Consent and authorization expire no later than one year from the date below unless the participant revokes it in writing prior to that time.\"},{\"question\":\"Can the participant or guardian revoke the authorization?\",\"answer\":\"Yes. The form states that the participant or parent/legal guardian can revoke or modify the authorization at any time in writing, with limits related to information already disclosed under the signed consent.\"}]","AUTHORIZATION FOR RELEASE - DISCLOSURE AND EXCHANGE OF INFORMATION - Revised July 2020 | PDF"]