MFA Consent to Exchange Information

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Participant Consent to Exchange Information with other Organizations/Individuals for Service Administration.

Email *

First and Last Name *

Last 4 Digits of Social Security Number *

Address *

Phone Number *

I want the following confidential information (except diagnosis or treatment related to alcohol, substance use and/or other medical not related to services) to be exchanged. *

Assessment Information

Financial Information

Benefits/Services Needed

Education Records

Criminal Justice Records

Employment Records

Other:

Required

I want MFA/Moving Forward Agency (LTE/Learn to Earn, Inc.) and MFA Staff (804.453.2343) to exchange information with the following other Organizations/Individuals for Eligibility Determination, Service Coordination, Assessment, Planning, and Implementation of Program Services. The Virginia Department of Social Services collects data to validate funds used for services. Information including biographic and demographic information will be provided to VDSS through monthly and quarterly reports submitted by MFA/LTE. : *

Virginia Department of Social Services (Data Validation)

_____________________________________ Local Department of Social Services

Kubix Consulting (MFA Counseling/Mental Health Partner)

________________________________________________________________________

Required

This Consent is Good Until (12-months after signature date, unless otherwise Indicated or until consent is revoked in writing by the participant): *

YYYY

I can withdraw this consent at any time by telling MFA in writing to cancel this document. I have the right to know what information is shared and with whom. If I do not sign this form, I will be responsible for contacting each agency individually to share information regarding what is needed for MFA to manage my case for this program. By signing this form you are providing Consent for Coordination of Program/Case Management Services with the individuals/organizations listed above. *

Yes, I Consent. Please type in your signature in the next question, confirming your consent.

Required

Consent Signature of Applicant *

A copy of your responses will be emailed to the address you provided.

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