9-Attachment H- Form 115C Release and Disclosure.pdf

DWS-WDD 115C

Rev. 10/2017

State of Utah Department of Workforce Services

RELEASE/DISCLOSURE OF INFORMATION &

CONSENT FOR COORDINATED SERVICES

ONLY for use by Contracts and Refugee Home Visits

Where UWORKS is Unavailable

Name (Print) PID Case #

I understand that my records are protected under the State and Federal regulations as well as professional codes of ethics governing confidentiality and cannot be released or disclosed without my written consent, unless otherwise provided for in the State and Federal regulations.

I authorize the release and/or disclosure of information only to the agencies listed below with the restriction that the information cannot be passed on to any other person or entity/agency …………… Yes No

Div. of Child & Family Services

Div. of Services for People with Disabilities

Div. of Juvenile Justice Services

Job Corps Juvenile Court Local Mental Health Providers

School Districts State/Local Health Department Substance Abuse Treatment Providers

Vocational Rehabilitation Social Security Administration Any & All Employer/Worksite

Other ___________________ Other ___________________

The information selected below is to be released and/or disclosed to coordinate a variety of services on my behalf. In order to provide these services, representatives of public and private agencies may be working together and may need to share information about me with one another.

I authorize the information below to be released from and/or disclosed to the agencies selected above to assist the Department of Workforce Services (DWS) in coordinating services for me. I only authorize the release and/or disclosure of the specific items checked below. I understand that this consent is effective from the date below until the final day of the month following the termination of my currently open program(s) with DWS. I understand I may revoke this consent at any time by sending written notification to my Employment Counselor.

Note: DWS does not disclose controlled documents without consent of the DWS Legal Department.

R=Release my information from a third party to DWS D=Disclose my information from DWS to a third party

R D R D R D

Employment Information (wages, hours worked, schedule, etc.)

Employment Plan Development/Renegotiation

Legal Information (court documents/orders, etc.)

Addt’l. Monitoring Information (WSL, CTW, job leads/contacts, etc.)

School Information (progress, attendance, schedule, etc.)

Treatment Information (plan, schedule, attendance, etc.)

Other _____________________ Other ___________________ Other _________________

Other _____________________ Other ___________________ Other _________________

Signature of Customer Date

Signature of Parent or Guardian, if under age 18 Date

Equal Opportunity Employer Program Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162

D26823900950101

Attachment H