I (Young Adult) blank hereby authorize the release of confidential information consisting of (psychiatric records or information, psychiatric medications, drug/alcohol records or information, HIV or AIDS information. medical records or information; social history; psychological records or information, educational or school records, assessments, service/treatment plans, all records of The Faine House, Inc.)
I (young adult name) blank hereby authorize the release of confidential information consisting of Psychiatric Records or Information, Psychiatric Medications, Drug/Alcohol Records or Information, HIV or AIDS Information, Medical Records or Information; Social History: Psychological Records or Information, Educational or School Records, Assessments, Service/Treatment Plans, All records to The Faine House, Inc.
For the purpose of assisting with The Faine House services:
I understand the information released by signing this form may be further disclosed by the recipient and is then no longer protected by the Federal code as required by 45 CFR 164.508 ( c )(2)(iii).
This consent or authorization for release of information shall be effective the date of signature and shall expire one (1) year from the date of signature or may be revoked at any time, provided I notify the program in writing to this effect. Revocation has no effect on action previously taken.