10.06A Policy Revisions - Data Practices Policies

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CONSENT TO RELEASE PRIVATE DATA MAINTAINED BY THE CITY OF PEQUOT LAKES You have asked the City of Pequot Lakes (City) to release data that the City keeps about you to the entities (includes people, agencies or organizations) listed on this form. The data cannot be released without your consent. This form tells the City what data you are asking the City to release and what will happen if you give your consent. Because the City does not have statutory authority to release the data, it must get your informed consent following an explanation of your rights before releasing the data. See Minn. Stat. § 13.05, subd. 4(d) and Minn. R. 1205.1400, subpart 4. EXPLANATION OF YOUR RIGHTS • You have the right to choose the data the City releases. This means you have the right to let the City release all of the data, some of the data or none of the data described on this form. The City can release only the data you choose. • You also have the right to let the City release data to all, some or none of the entities listed on this form. The City can release data only to the entities you choose. In short, you have the right to choose which entities receive data from the City and the specific data each entity receives. • You have the right to ask the City to explain the consequences for giving your permission to release the data. • If you give the City your consent, the City can release the data until copies of the data are provided to the entities you specify. Once such data is provided to the entities, such informed consent shall terminate and be of no further effect. • You have the right to stop your consent (withdraw, revoke or take back your permission) any time before this release occurs. Withdrawing your consent will not affect the data that the City has already released because the City had already received your prior permission to release the data. • If you want to stop or withdraw your consent, you must write to Nancy Malecha, City Administrator, at the address written herein, and clearly state that you want to withdraw all or part of your consent. • If you have a question about anything on this form or would like more explanation, please contact Nancy Malecha, Ciri� Administrator, City of Pequot Lakes, at 4638 Main Street, Pequot Lakes MN 56472 or by calling (218) 568-5222. INFORMED CONSENT I, , give my permission for and consent to the City of Pequot Lakes, Minnesota to release data about me to , as described on this form. 1. I understand that, if the data described herein are released to the entities or person(s) authorized herein, the result(s) will be that such entities or person(s) may use the data for any purposes the entities or person(s) chooses and the City is not responsible for how such data is used by such entities or person(s). Informed Consent Page 1