RYAN WHITE PROGRAM
MECKLENBURG COUNTY
HEALTH DEPARTMENT
NAME:
DOB:
INFORMED CONSENT FOR SERVICE/TREATMENT/
RELEASE OF INFORMATION REQUEST FOR TREATMENT
I,
Print Name First Middle Last
, give my consent for the _____________________________________________________ staff to perform appropriate
Service Provider laboratory and diagnostic test(s), appropriate physical examination(s), and appropriate related service(s) for purpose of diagnosis, treatment, management, prevention, and /or referral in the program area for which I am seeking services. I understand that my willingness to participant in case management and other core and support services, under the Ryan White Program (A, B, C, D, &
MAI) will allow access to my records for programmatic and fiscal monitoring compliance and quality assurance.
All information submitted is confidential and will be used for treatment, payment and operation purposes. I understand that all records, documents and funding used under the Ryan White Modernization Treatment Act will be reviewed for programmatic and fiscal monitoring for compliance and service.
If I believe I have been discriminated against due to race, color, age, national origin, sex, or disability, I should write the Ryan White Program Manager, Mecklenburg County Health Department, 618 S. College Street
Charlotte, N.C. 28202.
ACKNOWLEDGEMENT OF INFORMED CONSENT consent
I understand this consent is voluntary and I may revoke it at anytime, except to the extent that action based on this consent has been taken. I understand federal and state law (NCGS 130A-143 & 8-53) protects the confidentiality of this information and will not be disclosed without written consent except as stated above. This consent is valid for one year from the date of signature.
I have had the opportunity to ask questions and my questions were answered to my satisfaction.
__________________________________________________________________________________________________________
Patient/Parent/Guardian signature: Date:
Witness signature: ________________________________ Date: __________________________________

I have been provided access to _____________________________________________________ Notice of Privacy Practices.
Service Provider
Signature _________________________________________
(Patient or Authorized Representative)
Date ________________________
Relationship to Patient ___________________________________________________________________
Reason Patient Unable/Unwilling to Sign
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Revised: 6/22/09