Release of Information

Consent For Release of Information

  • PGC Counseling has my permission to exchange the information checked below to/from:
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  • Items Covered by this release of information: (A separate release is required to release HIV related information)
  • Send:
  • Receive:
  • By signing this consent, I am giving the authority to provide information from my confidential case record to the person or agency listed above. I understand that I do not have to provide such consent, and do so freely. I also understand that I can revoke this consent at any time by providing PGC Counseling with my intent to do so. I understand that this consent is valid for one year after the date of my signature unless otherwise indicated below. I understand that the information used or disclosed may not be subject to re-disclosure by the facility receiving it, and would then continue to be protected by federal agency regulations.
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  • is physically unable to sign this consent. I verify that he/she understands the nature of this release and freely gave his/her consent.
  • Date Format: MM slash DD slash YYYY
  • Prohibition of Disclosure: The information has been disclosed to you from whose confidentiality is protected by federal law. Federal regulations prohibit you from making any further disclosures of this information except with the specific written consent of the person whom it pertains or as otherwise permitted by such regulations. A general release of information is NOT sufficient for this purpose.
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