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INAME OF CONSUMER, PARENT, GUARDIAN/LEGAL REPRESENTATIVE* authorize and request Department of Social Services (DSS) and Family Support Division (FSD) to disclose /release the below specified information of: Full Name* Phone Number* Date of Birth* Social Security Number* Email* STREET, CITY, STATE, ZIP* to Please SelectRandolph County Focus on Fatherhood/Brian WilliamsPowerhouse Community Development Corporation / Charles Stephenson (and staff) Please Select101 W. Coates St. Moberly, MO 65270601 Business Loop 70 W Suite 204, Columbia, MO 65201
THE PURPOSE OF THIS DISCLOSURE IS FOR PROGRAM PARTICIPATION, RESEARCH AND DATA COLLECTION.
THE SPECIFIC INFORMATION TO BE DISCLOSED IS THE ENTIRE FILE, BENEFITS RECEIVED AND CHILD SUPPORT RECORDS THAT FSD MAY RELEASE TO THE PARENT FROM HIS/HER OWN CASE FILE.
1. READ CAREFULLY: I understand that my information and records with the Department of Social Services are confidential by law. I understand that by signing this authorization, I am allowing the release of any and all of my information and records which I am authorized to receive as specified on this document whether past, present or created in the future up to the expiration or revocation date of this authorization, unless otherwise indicated. The protected information in my records may include medical treatment and/or evaluation information, mental/behavioral health information, information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), other communicable or environmental diseases and conditions, application for and/or receipt of public assistance benefits, alcohol/drug abuse information, and/or information concerning child abuse and neglect.
2. This authorization includes both information presently compiled and information to be compiled during your association or dealings with the Department of Social Services, during the specified time frame.
3. Unless otherwise indicated, this authorization becomes effective on the date of signature below and will expire one year from that date.
4. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so IN WRITING and present my written revocation to the Privacy Officer of the Department of Social Services at P.O. Box 1527, Jefferson City, MO 65102. I further understand that actions already taken based on this authorization, prior to revocation, will NOT be affected.
5. I understand that I have the right to receive a copy of this authorization. A photographic copy of this authorization is as valid as the original.
6. I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to receive services from the Department of Social Services. I understand that I may request to inspect or request a copy of information to be used or disclosed, as provided in 45 CFR Section 164.524. I understand that any disclosure of information carries with it the potential for redisclosure by the party receiving it and that the information may no longer be protected by law once it is in possession of the receiving party. If I have questions about disclosure of my information, I can contact the Privacy Officer of the Department of Social Services, my caseworker or designee.
My signature below acknowledges that I have read and understood the text above, and authorize the release of my confidential information.