FAMILY & CHILDREN FIRST COUNCIL OF ERIE COUNTY
CLIENT AUTHORIZATION FOR INFORMATION SHARING
I hereby authorize the Member agencies of the Family & Children First Council of Erie County, named on the reverse side of this Authorization, to
exchange, give, receive, share, or redisclose information in their records, from whatever source derived, related to my participation and that of my
Name of Child:
Date of Birth:
Social Security #
in the services provided by one or more of these agencies.
I understand the following:
1. The purpose of this information sharing is to improve the communication about services to me and my family.
2. Each of the member agencies has agreed:
to share this information only with other member agencies:
b) not to share information with non-member agencies without my written consent unless otherwise required or authorized by law; and
Information exchanged due to this authorization will not be used against me or my children for purposes of criminal investigation,
prosecution, or sentencing, unless otherwise required by law or judicial order.
3. Any and all rights to confidentiality, which I may have under state or federal law, will continue, except for information covered by
4. I may revoke this Authorization at any time except for information that has been previously exchanged.
5. This Authorization shall automatically expire 180 days from the date below unless I revoke it sooner.
6. This Authorization shall not restrict information sharing otherwise authorized by law.
I authorize sharing of the following information: (Circle and initial, if yes, and sign below)
Case Information: Identifying information, plus medical and social history, treatment/service history,
Psychological evaluations, IEP's, IFSP's, transition plans, vocational assessments, grades and attendance, financial
information and other personal information held by any of the member agenc