Release of Information

Release of Confidential Information

I voluntarily authorize the release of information to be used by the Resident Services Coordinations at IBA to link me with programs and services that I may need or desire.

The Resident Services 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.

(of Individual or Organization)
Explain OTHER

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.

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As your RSC, I agree to protect your right to privacy and confidentiality within the ethical and legal limitations of my position and profession.

  • Service referral (i.e. home health, in home services
  • Family stabilization
  • Financial resources
  • Protective Services (elder at risk, DCF, DPPC)
  • Counseling (i.e behavioral health, assessment)
  • Housing stabilization
  • Medical information/follow up
  • Education related
  • Family support and service coordination
  • Domestic violence
  • Case coordination
  • Concerns with tenancy