Get the free Consent to Make Referrals and Share Information

This document provides consent for the New York City Department of Youth and Community Development (DYCD) to share information and make referrals for DYCD-funded programs and services. It outlines the permissions needed for sharing personal information, the purpose of information sharing, and the data protection measures in place.

How to fill out consent to make referrals

How to fill out consent to make referrals

1. Gather all necessary information about the individual you are making referrals for.
2. Obtain a consent form, ensuring that it is the correct version for your needs.
3. Fill out the individual's personal details in the designated fields on the consent form.
4. Clearly specify the purpose of the referrals on the consent form.
5. List the specific services or professionals the referrals will be made to.
6. Explain to the individual what they are consenting to, including any potential risks or benefits.
7. Obtain the individual's signature on the consent form, confirming their agreement.
8. Provide a copy of the signed consent form to the individual for their records.

Who needs consent to make referrals?

1. Any healthcare provider or professional making referrals for a patient or client.
2. Social workers involved in connecting individuals with social services.
3. Mental health professionals providing referrals for additional support.
4. Organizations coordinating care for individuals requiring multiple services.
5. Educators seeking to refer students to special services or programs.

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What is consent to make referrals?

Consent to make referrals is a formal agreement that allows a healthcare provider to refer a patient to another provider, agency, or specialist for additional services or treatment, typically requiring the patient's or guardian's authorization.

Who is required to file consent to make referrals?

Healthcare providers, organizations, or any professionals who wish to refer patients to other services or specialists are required to file consent to make referrals.

How to fill out consent to make referrals?

To fill out consent to make referrals, providers must complete the designated form by entering patient details, specifying the service or specialist to whom the patient is being referred, and obtaining the required signatures from the patient or guardian.

What is the purpose of consent to make referrals?

The purpose of consent to make referrals is to ensure that patients are informed about and agree to the sharing of their personal health information and that they are aware of and authorize the referral to another healthcare provider.

What information must be reported on consent to make referrals?

The information that must be reported includes the patient's name, date of birth, the referring provider's information, details of the referral (such as specialty and services needed), and signatures of the patient or guardian.