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SSVF: Authorization of Release of Information

  • I hereby authorize Passage Home Inc. to share information regarding my participation in the Supportive Services for Veteran Families Program. This program is designed to prevent homelessness and help homeless households move quickly into housing. The Authorization is designed to permit those organizations to share client information in order to collaborate on services and promote housing stability.
  • Mayors Challenge Taskforce to End Veteran Homelessness (This taskforce is made up of various agencies who are working together to end veteran homelessness). Participating agencies include staff from the following agencies: (Please check all).

  • I understand that this information will also be used for: The Mayor’s Challenge Taskforce which is made up of several agencies as described above who are working together to end veteran homelessness. Information released may be verbal, electronic, or written.  Release data may include records, treatment notes, and other information. 

    I understand     that this information will be used for:  The Mayors’ Challenge Taskforce meeting which occurs weekly to monitor a by name list of homeless veterans.  Information shared in this meeting will be used to expedite referrals of qualifying individuals to various supports & housing. 

    Nature of records to be released (use dates/timelines and names of documents when possible)

    -Current Living Status               -Length of Homeless Episode             -Diagnostic Information
    -Veteran Discharge Status       -Disabling Conditions                           -Substance Abuse/Treatment Information
    -Prior Living History                  -Credit Background Information        -Criminal Background Information

    My signature below indicates that I understand what information will be released and the need for the information.  I further understand that the information to be released may include information drug and alcohol abuse or AIDS/HIV.  In addition, information related to drug and alcohol abuse in my records is protected under federal regulations and cannot be disclosed pursuant to the signed authorization, I understand the federal privacy law (45 CFR Part 164) protecting health information may not apply to the recipient of the information and, therefore, may not prohibit the recipient from re-disclosing it.  Other laws may prohibit re-disclosure.  When we disclose mental health and developmental disabilities information protected by state law (G.S. 122C) or substance abuse treatment information protected by federal law (42 C.F.R. Part 2), we must inform the recipient of the information that re-disclosure is prohibited except as permitted or required under these two laws.  Our Notice of Privacy Practices describes the circumstances where disclosure is permitted or required by these laws.
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  • (specific date, event or condition, not more than 365 days from signature). I understand that I may revoke this consent, verbally or in writing, at any time, but that it will remain valid to the extend release based on this consent has already occurred.
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