Phoenix Preferred Care Agreement and Authorization for Involvement In the interest of

My signature below hereby verifies and declares that I am the parent and/or legal guardian of the child/adolescent named above, and 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 to my child, including consultation with agencies which may or may not have had direct contact with my child prior to this agreement.

I recognize that disclosure of information about my child 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/ Juvenile Courts / Court Designated Worker

e. Other individuals with whom child 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 my child is receiving, as well as to provide other services as outlined in my child’s Service Team Plan.

I agree to participate with both the letter and spirit of the interventions we design in my child’s Service Team Plan. In the event that I am in disagreement with the actions in my child’s services, 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 child’s 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.