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.