COLLABORATION CONSENT FORM

Ada S. McKinley Community Services, Inc.

Purpose:  This form is to be used to obtain permission to exchange information with other agencies also providing services to the client.  The purpose of this form is to obtain consent for Ada S. McKinley Community Services, Inc. (Agency) to coordinate service planning and delivery with representatives of established referral agencies.  The representatives of these agencies may participate in scheduled meetings and record reviews and may obtain copies of information specific to case coordination.  This form is also being used to obtain permission to use to use, publish, republish and/or disclose with or without identification any and all photographs, videos, films, drawings and other likenesses still or moving, taken or made and statements referring to and in conjunction with desires.

In order to coordinate service planning and delivery, the Agency expects to exchange information established agencies.  This release authorizes a free exchange of information including, but not limited to, participation in scheduled meetings, review of records, or exchange of copied information for the purpose of securing services in order to meet the programming needs and to assist in achieving goals and improving skill level.

This information is protected under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), governing the privacy of client health information, (including the HIPAA Privacy Rule), The Mental Health and Developmental Disabilities Confidentially Act, Americans with Disabilities Act, The Nursing Home Care Act, and other federal and Illinois statutes and regulations. Representatives of the agency, identified above, are required to adhere to confidentiality laws identified in this document. Furthermore, the agency named above may not disclose this information legally to another party without written consent.

I hereby give consent and permission to Ada S. McKinley Community Services, Inc. and its representatives to use, publish, republish and/or disclose with or without identification any and all photographs, videos, films, drawings and other likenesses still or moving, taken or made and statements referring to and in conjunction with desires. I further authorize the Agency and its representatives to use, publish, disclose or disseminate statements with promotions.

This consent to disclose photographs and statements is valid for a period of 12 months, but the consent to republish or re-disclose shall continue to be valid after 12 month period until such time as I revoke my consent.

I further waive, release, discharge and disclaim any rights or claims to payment or compensation for this release or the use of likeness, and waive, release, discharge and disclaim any damages or injuries which may occur as a result of this consent.

I understand that I have a right to inspect and to obtain a copy of any photographs taken by the Agency, its employees or agents. I may arrange for inspection and/or copy by contacting the Agency. The Agency will provide me with one (1) copy of each photograph free of charge at my request.

I understand that I may revoke this consent at any time by contacting the Agency, and that I will suffer no consequences of any type from the Agency.

By signing this agreement, I give Ada S. McKinley Community Services, Inc. permission to share information on my behalf with established agencies, and to use to use, publish, republish and/or disclose with or without identification any and all photographs, videos, films, drawings and other likenesses still or moving, taken or made and statements referring to and in conjunction with desires.  Unless revoked in writing, this agreement and exchange shall remain in force for a period of 12 months from the date of authorization.

I understand that I have the right to revoke this agreement and may do so in writing at any time.  If I do not sign this form or revoke the authorization, information will not be shared and I will have to contact each agency individually to give information whenever it is needed.

  • I understand that I have the right to revoke this agreement and may do so in writing at any time.  If I do not sign this form or revoke the authorization, information will not be shared and I will have to contact each agency individually to give information whenever it is needed.
  • (If student is over the age of 18.  If student is over the age of 18 but has a legal guardian appointed by the court, the legal guardian must sign)
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  • (If under the age of 18, a parent or a legal guardian appointed by the court must sign).
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