• CONSENT FOR USE OF PRIVATE DATA BY
    MAHUBE-OTWA COMMUNITY ACTION PARTNERSHIP, INC.

    Mahube-Otwa Community Action Partnership, Inc., hereinafter MAHUBE-OTWA, is a private Minnesota non profit corporation. MAHUBE-OTWA’s mission is, “To empower people to achieve self-sufficiency.” MAHUBE OTWA is asking for your consent (permission) to let MAHUBE-OTWA use private data that we keep about you for the purpose(s) or in the way(s) described on this form.

    We cannot use the data in the way(s) stated on this form without your consent.

    This form tells you what data we need to use and the reason(s) why we need to use the data in this way. This form also explains what will happen (consequences) if you let us use the data in this way.

    With whom may we share information? We will only share information about you as needed and as allowed or required by law. We may share your information with the following agencies or persons who need the information to do their jobs:

    • Employees or volunteers with other state, county local, federal, collaborative, nonprofit and private agencies.
    • Researchers, auditors, investigators, and others who do quality of care reviews and studies or commence prosecutions or legal actions related to managing the human services programs.
    • Court officials, county attorney, attorney general, other law enforcement officials, child support officials, and child protection and fraud investigators.
    • Human services offices, including child support enforcement offices.
    • Governmental agencies in other states administering public benefits programs.
    • Health care providers, including mental health agencies and drug and alcohol treatment facilities.
    • Health care insurers, health care agencies, managed care organizations and others who pay for your care.
    • Guardians, conservators or persons with power of attorney.
    • Coroners and medical investigators, if you die and they investigate your death.
    • Credit bureaus, creditors or collection agencies, if you do not pay fees you owe to us for services.
    • Anyone else to whom the law says me must or can give the information.

    You have the right to look at all the data described on this form and have copies of the data. We encourage you to look at the data before you decide whether to give your consent. If you want to look at the data or have copies, you must make a data request. To make a data request, contact the Agency Operations Manager at (218) 847-1385.

    If you give us your consent, we can use the data for internal use for one (1) year.

    You have the right to stop your consent (revoke or take back your permission) any time before the above referenced time period. If you want to stop your consent, you must write to: Mahube-Otwa Community Action Partnership, Inc., Attention Human Resources, P.O. Box 747, Detroit Lakes, MN 56502-0747, and clearly say that you want to stop or take back all or part of your consent. We cannot stop the use of data that we already have used because you gave your consent.

    MCAP Form No. 121 (03/13/2026); Page 1 of 2 Tennessen Privacy Notice