Client Consent

CASE# __________________________

Administration for Children and Families, Immediate Disaster Case Management

U.S. Department of Health and Human Services BCFS

CLIENT CONSENT TO THE RELEASE OF CONFIDENTIAL INFORMATION INSTRUCTIONS

MANDATORY FOR OPEN CASES

Signing and returning this form authorizes the U.S. Department of Health and Human Services and BCFS to share certain personal information collected about you or your family with FEMA and other disaster relief and voluntary organizations.

The U.S. Department of Health and Human Services and BCFS need to share this information in order to coordinate available disaster relief services and assistance, and to reduce the paperwork and applications necessary for you or your family to receive disaster relief assistance and services from multiple relief organizations. By use of this form and signature (below), disaster relief organizations acknowledge a commitment to respect your privacy and use the information solely for the purpose of coordinating and providing disaster relief assistance.

With the exception of certain limited circumstances, it is the policy of the U.S. Department of Health and Human Services and BCFS not to release information about individual or family disaster relief assistance, or other personal information obtained through the provision of disaster relief services, without the written consent of the individual or family. Therefore, we need your written consent to share this information and assist you and/or your family to obtain disaster relief services efficiently and effectively.

CONSENT AND RELEASE

I, , hereby authorize the U.S. Department of Health and Human Services and BCFS to share any of my information in its possession, including, but not limited to, my name, address and other personal information as well as the type of assistance I am receiving from FEMA, other disaster relief, and voluntary organizations for the purpose of coordinating disaster relief services and assistance available to me.

If you wish to limit this release to specific information, please specify the information that may be released:

I understand that I may revoke this consent at any time by contacting (U.S. Department of Health and Human Services and BCFS) except when action has already been taken to obtain and/or release such information to organizations. My signature on this release indicates that I have read the above, or had it read to me, and that I understand the terms and conditions. I have also had the opportunity to ask any questions. I am also signing this release on behalf of my children that are under the age of eighteen (18).

Signature Head of Household or Verbal Consent Date

Signature Co-Applicant Date

Client Consent (06/22/2015) Page 1 of 1