Confidentiality Form

Client Notice of Rights/Confidentiality Form

As a client of Freedom Service Dogs, you have the following rights regarding the confidentiality of your personal information and communications with FSD staff:

  1. The information that you provide to FSD will be kept confidential to the greatest extent allowed by law. This information can and will be shared across the organization on a need-to-know basis. Any information disclosed to any member of the FSD staff that would affect the success of your match or the safety of you, FSD staff, or FSD dogs, will need to be shared by the staff member with FSD leadership.
  2. The information that you provide to FSD, including your name, address, phone number, and other personal information will not be shared with other individuals outside of FSD or other agencies without your permission.
  3. FSD staff may be required by law to report certain situations even if you don’t give them permission to share or report the situations, such as suspected child abuse or neglect.
  4. Some general information about the types of services provided and overall demographics (e.g., age, location, disabilities, and ethnicities) of people that use FSD services must be shared with the agencies that fund FSD. Anytime information of an identifying information is required, such as when providing information to your sponsor, we will refer to you and your media release prior to doing so.
  5. You can decide how much or how little of your personal information FSD will or will not be shared with individuals and organizations outside of FSD, including sponsors. If you choose to have FSD share some of your personal information with a sponsor or funder, you will be told what information will be shared. If you later decide that you don’t want the information you have provided to be shared with any of these partners, let us know and we won’t share any more information with those partners.
  6. If you have any questions or concerns about this notice or your rights, please contact Amanda Vallo at 303-922-6231, or if you have a concern that your confidential information was not treated appropriately, please contact Michele Ostrander at 303-922-6231.
I,
Name
, have received notice of my rights to confidentiality.
Date:(Required)