I authorize Northwestern Mental Health Center (NWMHC) and those employed by NWMHC to release information concerning suspected abuse or neglect to the Minnesota Adult Reporting Center (MAARC) and/or County Common Entry Point if there is reasonable cause to believe that I am being or have been abused or neglected. For the purpose of compliance with mandatory reporting requirements under Minnesota Law. (MN Statutes: 626.557 subdivision 3a (1))
Federal Law (42 CFR Part 2), prohibits the above-named program from disclosing client identifying information in a report of suspected maltreatment, unless the vulnerable adult's guardian, conservator, or legal representative has consented to disclose in a manner, which conforms to federal requirements.
This consent to the disclosure must be signed by the client, guardian, conservator or legal representative to contact the program's reporting point to report the information concerning suspected abuse or neglect.
This consent is subject to revocation at any time, except to the extent that the program, which is to make the disclosure, has already taken action in reliance on it. If not previously revoked, this consent will terminate upon release from the above-named service/program (SUD).
If the client, guardian, conservator or legal representative will not sign this consent to the disclosure to release information to the reporting authorities this report may not be made.