Navmc 11720 Usmc Family Care Programs Consent To Release Information

MCO P1710.30E
OMB No. 0703-XXXX

USMC FAMILY CARE PROGRAMS CONSENT TO RELEASE INFORMATION

OMB approval expires

PRIVACY ACT STATEMENT
AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; DoD Instruction 6060.02, Child Development
Programs; DoD Instruction 6060.4, Youth Programs; OPNAVINST 1700.9 series; Marine Corps Order 1710.30, Marine Corps Child and Youth
Programs (CYP); and SORN NM01754-3
PURPOSE: The primary purpose of this form is to obtain consent for information about a patron participating in a Marine Corps Family Care Programs
(MFP) between MFP personnel and other designated individuals or organizations. The information exchanged will support authorized MFP services to
the patron.
ROUTINE USES: Any release of information contained in this system of records outside of DoD will be compatible with the purposes for which the
information is collected and maintained. The DoD Blanket Routine uses may apply to this system of records.
DISCLOSURE: Providing information is voluntary; however, failure to complete the form will limit MFP's ability to communicate with organizations or
individuals outside of DoD and may adversely affect available services.
The public reporting burden for this collection of information is estimated to average 1.17 hours (70 minutes)per response, including the time for
reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of
information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing the
burden, to the Department of Defense, Washington Headquarters Services, Executive Services Directorate, Directives Division, 4800 Mark Center
Drive, East Tower, Suite 03F09, Alexandria, VA 22350-3100 (0703-XXXX). Respondents should be aware that notwithstanding any other provision of
law, no person shall be subject to any penalty for failing to comply with a collection of information if it does not display a currently valid OMB control
number.
PLEASE DO NOT RETURN YOUR RESPONSE TO THE ABOVE ADDRESS.
Responses should be sent to your Regional Director.
I authorize the following agencies and/or individuals to exchange information pertaining to:

DRAFT NOT
FOR USE
2. Date of Birth

1. Name

3. Agency Name, Title, and Name of Specific Staff Contact Person or Designee

Additional agencies who may exchange information are listed on the back

Yes

No

SOURCE AND TYPE OF INFORMATION

5. Other Information that may be released or exchanged.
(please specify or enter N/A):

4. This authorization applies as followings.
YES

NO

Assessment Information

Educational Records and Information

Mental Health/Psychiatric/Psychological Records and Information

6. The form of information that may be exchanged: (please initial):

Health and Medical Records and Information

Written

Verbal

Computerized Data

7. This information may be exchanged for the following purposes: (please initial all that apply):
Service Coordination and Treatment Planning

Eligibility Determination

Inclusion Action Team Screening Tool

Other (specify):
ACKNOWLEDGEMENT
I understand this authorization and consent will remain effective for one year from date of signature unless I revoke it sooner by notifying the agencies
or individuals orally or in writing. This will stop the exchange of information authorized by this document. I understand that I have the right to know the
nature of the information being exchanged, and why, when, and with whom it was shared. A copy of this signed authorization and consent is valid to
exchange information. If I do not sign this form, information about me or my family member will not be exchanged and I will have to make other
arrangements to obtain and provide Family Care Programs personnel necessary information about me or my family member that is held by other
agencies
Date:

Signature

Print Name:
I am/are the (Check one):
Self

Parent/Legal Guardian or Custodian

Agent Acting Pursuant to a Power of Attorney

Mailing address:

Page 1 of 2
Reset Form
NAVMC 11720 (Rev. 08-2014) (EF)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE - Any misuse or unauthorized
disclosure can result in both civil and criminal penalties.

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MCO P1710.30E

INSTRUCTIONS FOR COMPLETING NAVMC 11720
USMC FAMILY CARE PORGRAMS CONSENT TO RELEASE INFORMATION
GENERAL
The NAVMC 11720 is completed by the Adult Exceptional Family Member (EFM); parent/legal guardian or custodian; or
Agent acting pursuant to a power of attorney of the EFM or Children, Youth and Teen Programs (CYTP) participant.
The form grants permission for EFMP and/or CYTP to exchange information for specific agencies and/or individuals
concerning the EFM and/or CYTP participant.
Item 1. Name of CYTP participant or EFM.
Item 2. Birth date of CYTP participant of EFM.
Item 3. Name and title of agencies and/or individuals that CYTP and EFMP can exchange information pertaining to the
CYTP participant or EFM. Answer Yes If permission is being granted to exchange information to additional agencies or
individuals and list them on the back of the form. Otherwise, answer No.
SOURCE AND TYPE OF INFORMATION

DRAFT NOT
FOR USE

Item 4. (Indicate as appropriate) Answer Yes for all that apply. Otherwise, answer No. Self-explanatory.
Item 5. Self-explanatory.

Item 6. Initial all that apply. Self-explanatory.
Item 7. Initial all that apply. Self-explanatory.
ACKNOWLEDGMENT

The adult EFM, parent/legal guardian or custodian, or Agent acting pursuant to a power of attorney must print his/her
name, sign and date the form. The signer must identify his/her relationship to the EFM and/or CYTP participant and
provide a mailing address.

Page 2 of 2
Reset Form
NAVMC 11720 (Rev. 08-2014) (EF)

FOR OFFICIAL USE ONLY

PRIVACY SENSITIVE - Any misuse or unauthorized
disclosure can result in both civil and criminal penalties.

Print Form
Adobe LiveCycle Designer 9