Women’s Release of Information READ FIRST: Before you decide whether or not to let DAIP share some of your confidential information with another agency or person, an advocate DAIP will discuss with you all alternatives and any potential risks and benefits that could result from sharing your confidential information. If you decide you want DAIP to release some of your confidential information, you can use this form to choose what is shared, how it's shared, with whom, and for how long.Name(Required) First Last Your Phone(Required)Email I allow DAIP to share the following specific information with:Who I want to have my information:Name Specific Office at Agency: Phone Number:The information may be shared: in person by phone by FAX by mail by e-mail Electronic mail (e-mail) is not confidential and can be intercepted and read by other people I understand What information about me will be shared:To receive credit for women's non-violence groupWhy I want information shared: (purpose)Women's Non-Violence Group Information (attendance and participation)Please Note: there is a risk that a limited release of information can potentially open up access by others to all of your confidential information held by DAIP.I understand that I do not have to sign a release form. I do not have to allow DAIP to share my information. Signing a release form is completely voluntary. That this release is limited to what I write above. If I would DAIP to release information about me in the future, I will need to sign another written, time-limited release. I understand I understand that releasing information about me could give another agency or person information about my location and would confirm that I have been receiving services from DAIP. I understand I understand that DAIP and I may not be able to control what happens to my information once it has been released to the above person or agency, and that the agency or person getting my information may be required by law or practice to share it with others. I understand This release expires on MM slash DD slash YYYY Expiration should meet the needs of the victim, which is typically no more than 15-30 days, but may be shorter or longer.I understand that this release is valid when I sign it and that I may withdraw my consent to this release at any time orally or in writing.Signature - Type your name below Date MM slash DD slash YYYY Please prove you're human.
