Form DWS-WDD115C "Release/Disclosure of Information & Consent for Coordinated Services" - Utah

What Is Form DWS-WDD115C?

This is a legal form that was released by the Utah Department of Workforce Services - a government authority operating within Utah. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Utah Department of Workforce Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DWS-WDD115C by clicking the link below or browse more documents and templates provided by the Utah Department of Workforce Services.

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Download Form DWS-WDD115C "Release/Disclosure of Information & Consent for Coordinated Services" - Utah

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DWS-WDD 115C
State of Utah
Rev. 10/2017
Department of Workforce Services
RELEASE/DISCLOSURE OF INFORMATION &
CONSENT FOR COORDINATED SERVICES
ONLY for use by Contracts and Refugee Home Visits
Where UWORKS is Unavailable
D02418900240101
Name (Print)
PID
Case #
I understand that my records are protected under the State and Federal regulations as well as professional
codes of ethics governing confidentiality and cannot be released or disclosed without my written consent,
unless otherwise provided for in the State and Federal regulations.
I authorize the release and/or disclosure of information only to the agencies listed below with the restriction
that the information cannot be passed on to any other person or entity/agency ……………
Yes
No
Div. of Child & Family
Div. of Services for People
Div. of Juvenile Justice
Services
with Disabilities
Services
Job Corps
Juvenile Court
Local Mental Health Providers
Substance Abuse Treatment
School Districts
State/Local Health Department
Providers
Vocational Rehabilitation
Social Security Administration
Any & All Employer/Worksite
Other ___________________
Other ___________________
The information selected below is to be released and/or disclosed to coordinate a variety of services on my
behalf. In order to provide these services, representatives of public and private agencies may be working
together and may need to share information about me with one another.
I authorize the information below to be released from and/or disclosed to the agencies selected above to assist
the Department of Workforce Services (DWS) in coordinating services for me. I only authorize the release and/or
disclosure of the specific items checked below. I understand that this consent is effective from the date below until
the final day of the month following the termination of my currently open program(s) with DWS. I understand I may
revoke this consent at any time by sending written notification to my Employment Counselor.
Note: DWS does not disclose controlled documents without consent of the DWS Legal Department.
R=Release my information from a third party to DWS D=Disclose my information from DWS to a third party
R D
R D
R D
Employment Information (wages,
Employment Plan
Legal Information (court
hours worked, schedule, etc.)
Development/Renegotiation
documents/orders, etc.)
Addt’l. Monitoring Information (WSL,
School Information
Treatment Information
CTW, job leads/contacts, etc.)
(progress, attendance,
(plan, schedule,
schedule, etc.)
attendance, etc.)
Other _____________________
Other ___________________
Other _________________
Other _____________________
Other ___________________
Other _________________
Signature of Customer
Date
Signature of Parent or Guardian, if under age 18
Date
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162
DWS-WDD 115C
State of Utah
Rev. 10/2017
Department of Workforce Services
RELEASE/DISCLOSURE OF INFORMATION &
CONSENT FOR COORDINATED SERVICES
ONLY for use by Contracts and Refugee Home Visits
Where UWORKS is Unavailable
D02418900240101
Name (Print)
PID
Case #
I understand that my records are protected under the State and Federal regulations as well as professional
codes of ethics governing confidentiality and cannot be released or disclosed without my written consent,
unless otherwise provided for in the State and Federal regulations.
I authorize the release and/or disclosure of information only to the agencies listed below with the restriction
that the information cannot be passed on to any other person or entity/agency ……………
Yes
No
Div. of Child & Family
Div. of Services for People
Div. of Juvenile Justice
Services
with Disabilities
Services
Job Corps
Juvenile Court
Local Mental Health Providers
Substance Abuse Treatment
School Districts
State/Local Health Department
Providers
Vocational Rehabilitation
Social Security Administration
Any & All Employer/Worksite
Other ___________________
Other ___________________
The information selected below is to be released and/or disclosed to coordinate a variety of services on my
behalf. In order to provide these services, representatives of public and private agencies may be working
together and may need to share information about me with one another.
I authorize the information below to be released from and/or disclosed to the agencies selected above to assist
the Department of Workforce Services (DWS) in coordinating services for me. I only authorize the release and/or
disclosure of the specific items checked below. I understand that this consent is effective from the date below until
the final day of the month following the termination of my currently open program(s) with DWS. I understand I may
revoke this consent at any time by sending written notification to my Employment Counselor.
Note: DWS does not disclose controlled documents without consent of the DWS Legal Department.
R=Release my information from a third party to DWS D=Disclose my information from DWS to a third party
R D
R D
R D
Employment Information (wages,
Employment Plan
Legal Information (court
hours worked, schedule, etc.)
Development/Renegotiation
documents/orders, etc.)
Addt’l. Monitoring Information (WSL,
School Information
Treatment Information
CTW, job leads/contacts, etc.)
(progress, attendance,
(plan, schedule,
schedule, etc.)
attendance, etc.)
Other _____________________
Other ___________________
Other _________________
Other _____________________
Other ___________________
Other _________________
Signature of Customer
Date
Signature of Parent or Guardian, if under age 18
Date
Equal Opportunity Employer Program
Auxiliary aids and services are available upon request to individuals with disabilities by calling (801) 526-9240. Individuals
with speech and/or hearing impairments may call Relay Utah by dialing 711. Spanish Relay Utah: 1-888-346-3162