Release of Confidential Information
I voluntarily authorize the release of information to be used by the Financial Empowerment Coordinations at IBA to link me with programs and services that I may need or desire.
The Financial Empowerment Coordinators at IBA are authorized to receive information pertaining to benefits or services provided to me. They are also authorized to provide information to the following service provider, individual, or organization in order to access, obtain, or maintain the services and/or supports I desire or need.
I understand that the use of this information is strictly confidential and that it may only be shared with those agencies and/or individuals indicated above. I also understand that I have the right to revoke this consent at any time.
As your Financial Empowerment Coordinator, I agree to protect your right to privacy and confidentiality within the ethical and legal limitations of my position and profession.