Consent to Release Data – Request from an Individual

An individual asks the government entity to release his/her private data to an outside entity or person.  Because the entity does not have statutory authority to release the data, it must get the individual’s written informed consent. 

Explanation of Your Rights 

If you have a question about anything on this form, or would like more explanation, please talk to

___________________________________________before you sign it.
[entity contact person name and contact information]
  
___________________________________________________________________________________ 

I, _____________________________________, give my permission for ________________________
	[name of individual data subject]					[name of government entity] 

to release data about me to __________________________________as described on this form.
				[name of other entity or person]  

1.		The specific data I want ________________________  to release ________________________. 

	 			    [name of government entity] 		[explanation of data]

2. 	I understand that I have asked ________________________ to release the data.
					  [name of government entity] 

3. 	I understand that although the data are classified as private at _________________________, the
									    [name of government entity] 
	classification/treatment of the data at ___________________________depends on laws or 
						 [name of other entity or person] 
	policies that apply to______________________________. 
				[name of other entity or person]  

This authorization to release expires _____________________. 
					[date/time of expiration]

Individual data subject’s signature ____________________________________ Date______________ 

Parent/guardian’s signature [if needed] ________________________________ Date______________ 

406-10F