ࡱ> IKH'` bjbj{P{P :4::| @@@@ 8( Dl 4;$> L 0C_#######$y&h(#o^oo#@@ #kkkoj@l  #ko#kkR!|," |; !6# $0;$!m)m)$"m)"kooo## ^ooo;$oooo  @@@@@@  [APPROPRIATE AGENCY LETTERHEAD] I understand that [Program/Agency Name] has an obligation to keep my personal information, identifying information, and my records confidential. I also understand that I can choose to allow [Program/Agency Name] to release some of my personal information to certain individuals or agencies. I, ___________________________, authorize [Program/Agency Name] to share the following specific information with: name Who I want to have my information:Name: Specific Office at Agency: Phone Number:The information may be shared:  FORMCHECKBOX  in person  FORMCHECKBOX  by phone  FORMCHECKBOX  by fax  FORMCHECKBOX  by mail  FORMCHECKBOX  by e-mail  FORMCHECKBOX  I understand that electronic mail (e-mail) is not confidential and can be intercepted and read by other people. What info about me will be shared:(List as specifically as possible, for example: name, dates of service, any documents).Why I want my info shared: (purpose)(List as specifically as possible, for example: to receive benefits).Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by [Program/Agency Name]. I understand: That I do not have to sign a release form. I do not have to allow [Program/Agency Name] to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would like [Program/Agency Name] to release information about me in the future, I will need to sign another written, time-limited release. That releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from [Program/Agency Name]. That [Program/Agency 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. This release expires on _____________ __________ Date Time I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time either orally or in writing. Date:______________ Signed:________________________ Time:______________ Witness:______________________      Template: Client Limited Release of Information Form Created for adaptation by Julie Kunce Field, J.D. and NNEDV. Expiration should meet the needs of the victim, which is typically no more than 15-30 days, but may be shorter or longer. READ FIRST: Before you decide whether or not to let [Program/Agency Name] share some of your confidential information with another agency or person, an advocate at [Program/Agency Name] will discuss with you all alternatives and any potential risks and benefits that could result from sharing your confidential information. If you decide you want [Program/Agency Name] to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long. Reaffirmation and Extension (if additional time is necessary to meet the purpose of this release) I confirm that this release is still valid, and I would like to extend the release until ___________ ___________ New Date New Time Signed:__________________________ Date:______________ Witness:_________________________ $%7Lg h s   3 ɴ蒂p`Q@ hzRhECJOJPJQJ^JhzRhEOJPJQJ^JhzRhE5OJPJQJ^J"hzRhE59OJPJQJ^J *h/hEOJPJQJ^Jh/hEOJPJQJ^J%hdhEB*OJPJQJ^JphO( *hdhEB*OJPJQJ^JphO<j *hdhEB*OJPJQJU^JmHnHphOuhaOJPJQJ^JhEOJPJQJ^J%I   $IfgdEl $$Ifa$gdzRl x^`gdEgdE$a$gdE |  V y }jP9<$IfgdzRl $<$Ifa$gdzRl  hx^`gdExgdE{kd$$Ifl0b|)" t0644 laytzR3 4 B C D O P Q _ ` a q r ݻݥݏycL-jhPhECJOJPJQJU^JaJ+jih/hEOJPJQJU^J+jh/hEOJPJQJU^J+jh/hEOJPJQJU^J+j h/hEOJPJQJU^JhEOJPJQJ^J+jh/hEOJPJQJU^Jh/hEOJPJQJ^J%jh/hEOJPJQJU^J V _ x > ? @ G a ӼxiXxiXL@1h/h20OJPJQJ^Jh20OJPJQJ^Jh*OJPJQJ^J hzRhECJOJPJQJ^JhzRhEOJPJQJ^JhzRhE6OJPJQJ^JhzRhE5OJPJQJ^J"hzRhE59OJPJQJ^J#hPhE6CJOJPJQJaJ-jhPhECJOJPJQJU^JaJ3jhPhECJOJPJQJU^JaJ$hPhECJOJPJQJ^JaJ ? gP<$IfgdzRl $<$Ifa$gdzRl }kdQ$$Ifl0p|) ! t0644 laytzR? @  h!'(^pqxxlllgg^Ygduy@ ^@ gdEgdE  & F<<gdE<<gd20}kd$$Ifl0p|) ! t0644 laytzR  D Y fg !"'<'(?ɹhWC'h(hE5CJOJPJQJ^JaJ!huy5CJOJPJQJ^JaJ,jh/hEOJQJU^JmHnHuhEOJPJQJ^J *h/hEOJPJQJ^Jh/hEOJPJQJ^Jh20hEOJPJQJ^Jh.|hE5OJPJQJ^Jh20OJPJQJ^J *h/h20OJPJQJ^Jh/h20OJPJQJ^Jh@YOJPJQJ^J?ACEIJKRUVXYZ\^lopq":<@AUXZkyz{|}뻫뉚{sosososohfjhfUjhEUmHnHu!hE5CJOJPJQJ^JaJ!hZ5CJOJPJQJ^JaJh/hE5OJPJQJ^Jhuy5OJPJQJ^JhECJOJPJQJ^JaJ$h(hECJOJPJQJ^JaJ'h(hE5CJOJPJQJ^JaJ(q"z|~yz|}RqgdE$ !@ ")a$gdEgdExgdgdZxgdE-DxyzƴƴưzhWIWhECJOJPJQJ^J hVhECJOJPJQJ^J#hVhE5CJOJPJQJ^Jh(hE6CJOJQJaJ huy56CJOJPJQJaJ h56CJOJPJQJaJhfhE#haB*CJOJQJ^JaJph333)hnhEB*CJOJQJ^JaJph333#hk/B*CJOJQJ^JaJph333#hEB*CJOJQJ^JaJph33334@ANmBDQqz{|}  qǾui]i]ihuyOJPJQJ^JhEOJPJQJ^J'h!hE5CJOJPJQJ^JaJhE5OJPJQJ^Jh&hE5OJPJQJ^J'h(hE5CJOJPJQJ^JaJhEhVhECJhECJOJPJQJ^J hVhECJOJPJQJ^J1hVhECJOJPJQJ^JfHq "q{hEh(hE5OJPJQJ^JhE5OJPJQJ^Jh/hE5OJPJQJ^J qgdE<gdE8 00:pE/ =!"`#$% $$If!vh55"#v#v":V l t06,55"ytzRtDeCheck3tDeCheck1tDeCheck2tDeCheck3tDeCheck3tDeCheck3$$If!vh55 !#v#v !:V l t0655 !ytzR$$If!vh55 !#v#v !:V l t0655 !ytzR<@< NormalCJ_HmH sH tH DA@D Default Paragraph FontZi@Z  Table Normal :V 4 l4a _H(k(No List @Z@@ Plain TextCJOJPJQJ4@4 iHeader  !4 4 iFooter  !6U@!6 }$ Hyperlink >*B*phj3j }$ Table Grid7:V0DBD n Balloon TextCJOJQJaJ{~    {~ 4%IVy?@h!'(^pq " z | ~  y z | } R q 000000000 000 0 000 0 0 0 0 0 00 0 0 00000000H@000@000@000@000@0@0000000000000\M 3 ?q  ? qq  3CP`q G$G$G$G$G$G$8 @t (     s X . `T`T`T`T3"`?    s X 1. kS~TkS~T 3"`? n   S  #" `? B S  ?!z `)4 W6*ZB *nTCheck1Check2Check3Qr a | | ~ ~   =B  ( * | | ~ ~   w y 333333 z | | ~ ~   | | ~ ~   qf GF">GJ:%@'R l&vew`hhh^h`OJQJo(hHh88^8`.hL^`L.h  ^ `.h  ^ `.hxLx^x`L.hHH^H`.h^`.hL^`L.hhh^h`OJQJo(hHh88^8`.hL^`L.h  ^ `.h  ^ `.hxLx^x`L.hHH^H`.h^`.hL^`L.hhh^h`CJOJQJaJo(hHh88^8`.hL^`L.h  ^ `.h  ^ `.hxLx^x`L.hHH^H`.h^`.hL^`L. pp^p`o(hH.^`OJQJo(hH L^`LhH.   ^ `hH. \ \ ^\ `hH. ,L,^,`LhH. ^`hH. ^`hH. L^`LhH.h ^`hH.h ^`hH.h pLp^p`LhH.h @ @ ^@ `hH.h ^`hH.h L^`LhH.h ^`hH.h ^`hH.h PLP^P`LhH.hhh^h`.h88^8`.hL^`L.h  ^ `.h  ^ `.hxLx^x`L.hHH^H`.h^`.hL^`L.:%ew l&qf F">         9RF                           }fT(k/2026>J<RMS6dku% g_JzR@Yduy*>bQ\aEZIVy?@ 3@S  p@UnknownGz Times New Roman5Symbol3& z Arial]  MS MinchoArial Unicode MS3z Times?5 z Courier New[bwKLucida GrandeCourier NewYWP IconicSymbolsASymbol 1h3d&5d&1d&00!4d^ ^ B 2QXi61Model Template Agency Release of Information Form$      Oh+'00      (4Model Template Agency Release of Information Formthis form is created so your agency can easily insert their agency/program name and letterhead and use it with clients/survivors. August 2008Normal3Microsoft Office Word@V@Fߓ@eہ@^"՜.+,D՜.+,p, px  0^ ' 2Model Template Agency Release of Information Form Title :B_PID_LINKBASEA6http://nnedv.org/safetynet  !"$%&'()*+,-./012345679:;<=>?ABCDEFGJRoot Entry F߈;LData 1Table#)WordDocument:4SummaryInformation(8DocumentSummaryInformation8@CompObjq  FMicrosoft Office Word Document MSWordDocWord.Document.89q