I understand that different agencies provide different services and benefits.  Each agency must have specific information in order to provide services and benefits.  By signing this form, I am allowing agencies to exchange certain information so it will be easier for them to work together effectively to provide or coordinate these services or benefits.

I,
(FULL PRINTED NAME OF CONSENTING PERSON OR PERSONS)

am signing this form for

(FULL PRINTED NAME OF CLIENT)

(CLIENT’S ADDRESS)	(CLIENT’S BIRTHDATE)	(CLIENTS SSN – OPTIONAL)

My relationship to the client is:	Self	Parent	Power of Attorney	Guardian
Other Legally Authorized Representative

I want the following confidential information (except drug or alcohol abuse diagnosis or treatment information) about the client to be exchanged:
Yes No	Yes No	Yes No	
Assessment Information
Financial Information
Benefits/Services Needed
Planned, and/or Received	Medical Diagnosis
Mental Health Diagnosis
Psychological Records
Current Medications	Educational Records
Psychiatric Records
Employment Records
Criminal Justice Records	

Other Information (write in):

I want:	The Educational Service Center of Lake Erie West/Alternate Learning Center
3939 Wrenwood Drive; Toledo, Ohio 43623	FAX (419) 473-3445
(NAME AND ADDRES OF REFERRING AGENCY AND STAFF CONTACT PERSON)

And the following agency to be able to exchange this information:

(Agency Name)	(Agency Address)	(Agency Phone Number)

I want this information to be exchanged ONLY for the following purpose(s):
Service Coordination and Treatment Planning	Eligibility Determination
Other (write in):

I want information to be shared: (check all that apply)
Written Information	In Meetings or By Phone	Computerized Data

I want to share additional information received after this consent is signed:	YES	NO

I can withdraw this consent at any time by telling the referring agency.  This will stop the listed agencies from sharing information after they know
my consent has been withdrawn.
I have the right to know what information about me has been shared, and why, when, and with whom it was shared.  If I ask, each agency will show me this information.
I want all the agencies to accept a copy of this form as a valid consent to share information.
If I do not sign this form, information will not be shared and I will have to contact each agency individually to give them information about me that they need.
Signature(s):		Date: (CONSENTING PERSON OR PERSONS)

Person Explaining Form:

(Name)	(Title)	(Phone Number)

Witness (If Required):

5-14-92
032-01-005

(Signature)	(Address)	(Phone Number)

This consent expires one year from today’s date.

UNIFORM CONSENT TO EXCHANGE INFORMATION FORM FULL PRINTED NAME OF CLIENT:

FOR AGENCY USE ONLY

CONSENT HAS BEEN:

Revoked in entirety
Partially revoked as follows:

NOTIFICATION THAT CONSENT WAS REVOKED WAS BY:

Letter (Attach Copy)	Telephone	In Person

DATE REQUEST RECEIVED:    	

AGENCY REPRESENTATIVE RECEIVING REQUEST:

(AGENCY REPRESENTATIVE’S FULL NAME AND TITLE)

(AGENCY ADDRESS AND TELEPHONE NUMBER)

Rev. 5/4/2015