10A NCAC 69 .0402 CONSENT FOR RELEASE OF INFORMATION
(a) The consent for release of information shall be on a form provided by the state Division of Social Services or shall contain the following:
(1) name of the provider and the recipient of the information;
(2) the extent of information to be released;
(3) the name and dated signature of the client;
(4) a statement that the consent is subject to revocation at any time except to the extent that action has been taken in reliance on the consent;
(5) length of time the consent is valid.
(b) The client may alter the form to contain other information which may include but is not limited to:
(1) a statement specifying the date, event or condition upon which the consent may expire even if the client does not expressly revoke the consent;
(2) specific purpose for the release.
History Note: Authority G.S. 108A‑80; 143B‑153;
Eff. October 1, 1981.