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Consent To Disclose - AL

This document is a consent form allowing the disclosure of a client's personal information to specific agencies and individuals. The client, Ashley Lehman, provides consent for her information held by the Ministry of Social Development and Poverty Reduction to be disclosed to BC Children's Hospital social worker Avery Marte. The information may be relevant to determining eligibility for income assistance or disability assistance. The consent is effective as of the date signed and will remain valid until revoked by the client.

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Ashley Lehman
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272 views1 page

Consent To Disclose - AL

This document is a consent form allowing the disclosure of a client's personal information to specific agencies and individuals. The client, Ashley Lehman, provides consent for her information held by the Ministry of Social Development and Poverty Reduction to be disclosed to BC Children's Hospital social worker Avery Marte. The information may be relevant to determining eligibility for income assistance or disability assistance. The consent is effective as of the date signed and will remain valid until revoked by the client.

Uploaded by

Ashley Lehman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CONSENT TO DISCLOSURE

OF INFORMATION
The personal information requested on this form is collected under the authority of and will be used for the purpose of administering the Employment and Assistance Act
and the Employment and Assistance for Persons with Disabilities Act. The collection, use and disclosure of personal information is subject to the provisions of the Freedom
of Information and Protection of Privacy Act. You have the right to revoke this consent at any time. Any questions regarding this form should be directed to your local
Employment and Assistance office.

CLIENT NAME

Ashley Lehman
SR NUMBER (IF APPLICABLE) CASE NUMBER (IF APPLICABLE)

1-18271166188
I consent to the disclosure of any personal information currently held under the custody and control of the Ministry of
Social Development and Poverty Reduction subject to the following limitations:

1. The following specific information only. (If more space is required, please attach an additional page)

2. All information relevant to the determination of eligibility for:


Income Assistance Hardship Assistance

Disability Assistance Supplements


This information may be disclosed to an agency and/or an individual:
AGENCY NAME INDIVIDUAL NAME

BC Children's Hospital - Social Work Avery Marte


ADDRESS

4500 Oak Steet


CITY / TOWN POSTAL CODE TELEPHONE NUMBER FAX NUMBER

Vancouver V6H 3N1 604-875-3227 604-875-2770


AGENCY NAME INDIVIDUAL NAME

ADDRESS

CITY / TOWN POSTAL CODE TELEPHONE NUMBER FAX NUMBER

This consent is effective on the date it is signed and will remain valid until I request that it be cancelled.

SIGNATURE OF PERSON GIVING CONSENT DATE (YYYY MMM DD)

NOTE: If you are signing on behalf of the Ministry Client, you must attach proof of that legal authority (for example, a copy of the court
order naming you as Committee) to this Consent.

HR3189(17/12/29)
Security Classification: MEDIUM SENSITIVITY Page 1 of 1

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