How to Get Your Information in an Informal Consent Form Article Information about the following topics is for informational purposes only.
Please do not use this information to seek legal advice.
Contact the Department of Justice, the Consumer Financial Protection Bureau, or the Department’s Bureau of Consumer Protection for further information.
Consent Forms are available from the Department or from other federal, state, and local agencies.
The forms are designed to be simple, clear, and easy to understand.
You can use your own or a copy of one provided by the person you are making a claim for.
Informed consent is a legally binding agreement that provides clear, explicit and effective ways for a person to give consent to a medical procedure or other activity, or to provide an accurate and up-to-date estimate of the risks involved.
If you need to use a form, you must follow these instructions: Ask the person to complete it.
Ask them if they want to share the information.
Make it clear to the person that you will provide the information only to the extent that the person agrees to receive it.
If the person declines, the person may be required to provide additional information.
If they decline to share, the information should be kept confidential and should be provided only if the person has a legal right to it.
If you do not want to receive your information in an oral or written form, write to the Department, the Federal Trade Commission, or your state attorney general’s office and ask them to write a form for you.
Informal consent forms must be submitted electronically, in person, or in writing.
Informally consent forms are available in the following formats: PDF format (PDF) or DOC format (DOC) format.
You may print your forms and keep them with your computer or print and return them to the address provided at the bottom of each form.
For more information about consent forms, go to the following link:Consent forms can be used by doctors and health care professionals, and health insurance plans, as well as individuals and families.
You must follow the directions on the form to get the information you want.
However, your choices about how to get your information can affect how you receive it and how you use it.
For example, if you use your health insurance plan, you should check your health plan’s policies for the most up- to-date information on the types of services it provides.
You should also review the requirements of your state’s health care insurance policies to be sure they apply to your plan.
You cannot use your personal information for marketing purposes.
You may want to ask your health care provider to get a copy for you before you enroll in your health plans.
The provider may ask you if you want to give your information to other people, or you may need to give it to a third party for marketing.
Do you need information about an insurance policy?
If you or your family are eligible for Medicaid, Medicare, Social Security, Supplemental Security Income, or other government benefits, you may want the following information.
You must complete and return this form, or call the Department and ask the person giving it to forward it to you.
The form must include: the name and address of the person providing the information; the person’s name and contact information; a description of the service or activity being provided; the date, time, and purpose of the information (for example, a list of all the medical services provided); the name of the provider providing the service; and any additional information you may require.
You may need a copy to prove you are eligible.
If so, you can get one from the health care professional, but you must return the form with the name, address, and signature of the health provider.
If it does not have this information, the health professional should have it.
The person providing it should sign the document.
The information is confidential and cannot be shared with anyone other than the person whose name is on it.
If you are a health care practitioner, your information is also confidential and may not be shared.
If your information includes the name or address of someone you do know, you will need to ask the provider or person providing your information about the privacy rights of that person.
You do not need to make a claim about someone who you know.
However and in some cases, you need the information to determine if you should have access to the information, and if you need access to it for a particular reason.
The information you provide should be accurate and complete.
You need to provide it when you need it.
It should be brief and clear.
The form must be mailed or delivered to the provider’s or person’s address or phone number.
If a form is not mailed, it should be delivered to your health professional’s or someone’s address in the state in which the provider is located or in which you or a member of your family live.
The health professional or person should keep the form in a locked, safe