Form Navmc 11720 PDF Details

Embarking on the journey through the realms of bureaucracy and legal documentation, the NAVMC 11720 form presents itself as a crucial piece of paperwork for those connected to the military sphere, particularly within the Marine Corps. This form, steeped in administrative protocols, serves a pivotal role in safeguarding the privacy and facilitating the exchange of sensitive information between agencies for service members or their dependents. At its core, the NAVMC 11720 form is an Authorization to Release and Consent to Exchange Information, requiring precise details such as the participant's relationship to the subject (be it parent, legal guardian, or agent acting under a power of attorney), along with the specific types of information that can be shared. From medical records to educational data, and even employment histories, this form spans a broad spectrum of personal information that might be necessary for coordinated service provision, eligibility determination, or treatment planning. The consent mechanism built into the document is robust, allowing for written, verbal, or computerized data exchanges, but always with the explicit permission of the signatory, who retains the right to revoke consent at any time. The form's legal underpinnings are further reinforced by a Privacy Act Statement, in line with the Privacy Act of 1974, detailing the purpose, retention, safeguarding, and routine uses of the collected information, emphasizing a commitment to privacy and the secure handling of personal data. Thus, the NAVMC 11720 form embodies a critical bureaucratic process, ensuring informed consent and the protected exchange of vital information within the military community.

QuestionAnswer
Form NameForm Navmc 11720
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesIDs, Dtermination, FOUO, navmc 11667

Form Preview Example

See Privacy Act Statement - Page 2
FOR OFFICIAL USE ONLY

AUTHORIZATION TO RELEASE AND CONSENT TO EXCHANGE INFORMATION

 

I/We,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I am/are the (Check one):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Parent(s)

 

 

Legal Guardian

 

 

 

 

Agent Acting Pursuant to a Power of Attorney, for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Name/student)

 

 

 

 

 

 

 

 

 

 

 

 

 

(Date of Birth)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

My/our mailing address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORIZATION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I authorize the following agencies and individuals to exchange confidential information pertaining to above named child/student:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Agency Name, Title, and name of Specific Staff Contact Person or Designee)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AND

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Agency Name, Title, and name of Specific Staff Contact Person or Designee)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Additional agencies who may exchange information are listed on the back

 

 

 

 

 

 

Yes

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SOURCE AND TYPE OF INFORMATION

 

 

 

 

 

 

 

 

 

My consent to the exchange of information (except drug or alcohol abuse diagnoses or treatment information) applies to the following sources of

 

information (initial all that apply):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Assessment Information

 

 

 

 

 

 

 

 

 

 

Financial Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychiatric Records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medical Records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Educational Records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employment Records

 

 

 

 

 

 

 

 

 

 

 

 

Psychological Records

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Criminal Justice Information

 

 

 

 

 

 

 

 

 

 

 

 

Mental Health Diagnosis

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Benefits/Services Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Information that may be released or exchanged (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The form of information that may be exchanged: (initial all that apply):

Written

 

 

 

Verbal

 

 

Computerized Data

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

This information may be exchanged for the following purposes: (initial all that apply):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Service Coordination and Treatment Planning

 

 

 

 

 

Eligibility Dtermination

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (specify):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ACKNOWLEDGEMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

I have read and understand this authorization and consent will remain effective until I revoke it by notifying the agencies or individuals orally or in

 

writing. This will stop the exchange of information authorized by this document. I understand that I have the right to know what information is being

 

exchanged, and why, when, and with whom it was shared. At my request, the named agency or individuals will show me this information. A copy of

 

this signed authorization and consent is valid to exchange information. If I do not sign this form, information will not be exchanged and I will have to

 

contact each agency individually.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Print Name:

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date:

 

Print Name:

 

 

 

 

 

Signature:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NAVMC 11720 (06-10) (EF)

FOUO - Privacy sensitive when filled in.

Adobe Designer 8

NAVMC 11720 (06-10) - Page 2

PRIVACY ACT STATEMENT

In accordance with the Privacy Act of 1974 (Public Law 93-579), this notice informs you of the purpose for collection of information on this form. Please read it before completing the form.

AUTHORITY: 10 U.S.C. 5013, Secretary of the Navy; 10 U.S.C. 5041, Headquarters, Marine Corps; and E.O. 9397 (SSN).

PRINCIPAL PURPOSE: Information collected by this form will be used to prove parent consent to share information. The information collected on this form will be filed within a Privacy Act Systems of Records collection governed by Privacy Act System of Records Notice MO 1754-6 which can be downloaded at http://privacy.defense.gov/notices/usmc/MO1754-6.shtml..

RETENTION AND SAFEGUARDS: SAMPLE: The collected information will be maintained in a database with restricted, limited access by authorized personnel who are properly screened, cleared, and trained. The database is protected by password, unique user IDs, and applicable layers of security access within applications. Records in this file system will only be retrieved by name and social security number. Records will be maintained indefinitely until a records disposition is approved.

ROUTINE USES: To various officials outside the Department of Defense specifically identified as a Routine Use in Privacy Act System of Records Notice MO 1040-2for the stated specific purpose in addition to those set out in the blanket routine uses established by the Department of Defense Privacy Office and posted at http://www.defenselink.mil/privacy/notices/blanket-uses.html.

DISCLOSURE: Providing information on this form is voluntary (select one). Note: If parent does not complete the necessary data fields, EFMP will be unable to communicate with identified outside agency.

How to Edit Form Navmc 11720 Online for Free

When you desire to fill out Dtermination, there's no need to download and install any kind of applications - just give a try to our online PDF editor. To maintain our tool on the forefront of efficiency, we strive to integrate user-driven capabilities and improvements regularly. We are at all times grateful for any feedback - play a vital role in reshaping PDF editing. With a few simple steps, you'll be able to begin your PDF editing:

Step 1: First, access the pdf editor by clicking the "Get Form Button" above on this webpage.

Step 2: With the help of our online PDF editing tool, it is easy to accomplish more than just fill out blanks. Try all the features and make your documents appear great with customized text added, or fine-tune the file's original content to excellence - all that backed up by the capability to incorporate any type of photos and sign the PDF off.

This form will need specific information to be entered, so you should take whatever time to enter exactly what is required:

1. Firstly, once filling in the Dtermination, begin with the section with the following fields:

Writing part 1 of 1040-2for

2. Once your current task is complete, take the next step – fill out all of these fields - Assessment Information, Psychiatric Records, Educational Records, Psychological Records, Mental Health Diagnosis, BenefitsServices Information, Financial Information, Medical Diagnosis, Medical Records, Employment Records, Criminal Justice Information, Other Information that may be, The form of information that may, Written, and Verbal with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

1040-2for writing process shown (part 2)

It is easy to make an error while filling in your Employment Records, so be sure you go through it again before you send it in.

3. The following section is normally quite easy, Print Name, Print Name, Signature, Signature, Date, Date, NAVMC EF FOUO Privacy sensitive, See Privacy Act Statement Page, FOR OFFICIAL USE ONLY, and Adobe Designer - each one of these empty fields is required to be filled out here.

1040-2for writing process shown (portion 3)

Step 3: Spell-check everything you have typed into the blanks and then click the "Done" button. Right after creating a7-day free trial account with us, you will be able to download Dtermination or send it through email promptly. The form will also be available in your personal account page with your each change. When using FormsPal, you can easily complete forms without needing to be concerned about data incidents or entries getting shared. Our protected software helps to ensure that your private details are maintained safe.

Form Navmc 11720 isn’t the one you’re looking for?

Related Documents