Permission to Use and Disclose Confidential Information (NY)

This uniform consent form is designed for organizations that collaborate with one another in planning, coordinating, and delivering services to individuals diagnosed with mental disabilities. It is for a multiple-county consortium in New York that permits use, disclosure, and re-disclosure of confidential information for the purposes of coordinated support efforts. Note, that in contrast to the Washington and California forms, each agency that is party to the local information sharing agreement is listed at the end of the form; the person providing consent can check off which agencies he or she consents to having access to his or her information.