Client Consent policies and procedures vary from organization to organization. The IRIS Client Consent Templates may be used to consider changes to current consent forms or used to craft new documents. The link below is a PDF version of the tool; please reach out to irisadmin@ku.edu for the Word version of this tool.

Using this Template

It is each IRIS Organization’s responsibility to develop and implement client consent practices appropriate to their work and relevant regulatory authorities. Organizations should involve staff well-versed in applicable rules and regulations when considering the impact of IRIS on their consent processes, workflows, and ability to exchange client information. 
 

The below template is offered to help organizations consider informed consent procedures. While the template reflects best practices for client consent, it is not intended to be prescriptive, nor does it comprehensively address each organization’s unique consent needs and responsibilities. Organizations who choose to use the template can and should adapt it to address workflow needs and any applicable privacy laws and/or confidentiality regulations (i.e., HIPAA, FERPA, 42 CFR Part 2, etc.).
 

AUTHORIZATION FOR RELEASE OF INFORMATION AND CONSENT FOR REFERRAL 

[AGENCY NAME] [PROGRAM NAME, IF APPLICABLE]

Our agency is one of a group of service providers working together to provide support for people in our community. Based on information you have shared, we believe that one or more programs in our community can provide you and/or your family with resources, supports, or services that will be helpful to you. With your permission, we can share your information with the program or programs that you choose. The program will contact you to discuss the services they can provide. This process is called a “referral.”

By signing this form, you agree that we can use an online system called IRIS to refer you to the programs and resources you choose. 

If you agree, your name and date of birth will be shared with service providers in the online system. Your date of birth will be used for identification purposes only. Other personal information will be shared only with staff at the program(s) we refer you to and the local IRIS Data Manager(s). They will only use your family’s personal information to coordinate services by sending a referral or contacting you to offer services. This personal information may include: 

• Details about you and/or family that will help the program(s) understand your needs (Example: household information, services requested, other programs you are referred to, etc.)
• Information that will help the program(s) know how to best contact you (Example: phone number, email address, home address, language spoken, etc.).
• Information about assessments you receive (Example: answers to questions about housing needs, tobacco use, prenatal care, etc.).

Our agency and the program we refer you to will also provide updates about the referral, including whether you receive services. 

Do you agree to allow us to share your and/or your family's information with partners who provide services in our community?

☐ Yes, my / my family’s information can be shared with other partners who provide services in our community and who will also secure my information. 

☐ No, my / my family’s information cannot be shared. (If you select this option, we will discuss a different way to make this referral.)

Organizations that serve minors or those bound by specific privacy laws and/or confidentiality regulations should consider the below elements along with other necessary clauses. 

Consent for minor

Consent expiration
This consent is valid from the date of signature until/if I decide to take back my permission.

Withdrawing consent
I am free to take back my permission at any time. I must provide this organization with a written and signed statement that includes the date I withdraw my permission. I do not need to give a reason.

Referral results consent
Program(s) I am referred to have permission to share the results of my referral with this agency without obtaining additional consent.