Phoenix Preferred Care Adult Agreement and Authorization for Involvement

My signature below hereby verifies and declares that I am requesting outpatient services through Phoenix Preferred Care.

I hereby give permission to those agencies and/or organizations affiliated with Phoenix Preferred Care to provide services, including consultation with agencies with which I may or may not have had direct contact with prior to this agreement.

I recognize that disclosure of information is necessary for interagency collaboration to occur and hereby give my permission for such to occur between:

a.The Department for Community Based Services

b. Mental Health Outpatient Providers

c.The Department of Education and Local School District

d. Representatives of Court Systems/ Probation and Parole

e. Other individuals with whom client may be accessing services

I understand that I may revoke this authorization at any time by signing the Revocation statement below.

I hereby grant to the employees of Phoenix Preferred Care permission to provide coordination of services, as well as to provide other services as outlined in my Treatment Plan / Service Team Plan.

I agree to participate with both the letter and spirit of the interventions we design in my Treatment Plan /Service Team Plan. In the event that I am in disagreement with the actions throughout my treatment, I understand that I may access either the internal agency and/or statewide grievance and appeal procedures.

in the interest of assisting in future needs assessments and program planning, I authorize data to be shared with the Department of Behavioral Health, Developmental and Intellectual Disabilities, as well as, my Insurance / Managed Care Organization.

With my signature below, I wish to set into motion the conditions of this agreement.

With my signature below, I hereby revoke the authorization contained in this agreement.