Authorization for the Use or Disclosure of Protected Health Information

As required by the Health Insurance Portability and Accountability Act (HIPAA) of 1996, your signature on this form indicates that you are giving permission for the uses and disclosures of protected health information described herein. You may revoke this authorization at any time by signing and dating the revocation section on your copy of this form and returning to this office.

As the parent or legal guardian of the above individual, I hereby authorize the use and/or disclosure of the following health information that pertains to this individual:

• Release of health information to or from a physician, hospital, or other health care provider for purposes of coordination of medical/behavioral treatment for the individual if necessary.
• Release of health information to or from referral source.
• Release of group curriculum information and attendance records to grantors and referral source
• Release of behavior information to referral source.

I understand that information disclosed pursuant to this authorization may be re-disclosed to additional parties and no longer protected.

I understand that I may revoke this authorization at any time by signing the revocation section of my copy of this form and returning it to CCYS/FS. I further understand that any such a revocation does not apply to the extent that persons authorized to use or disclose my health information have already acted in reliance on this authorization.

I understand that this authorization will automatically expire one year from the date of your submission.

I understand that I am under no obligation to sign this authorization. I further understand that the individual’s ability to participate in this program will not depend in any way on whether I sign this authorization or not. I understand that I have a right to inspect and to obtain a copy of any information disclosed pursuant to this authorization.

I understand that I have been advised to seek legal counsel of my choice to review this authorization document. By signing this agreement, I acknowledge that I have been advised by my own legal counsel or that I have voluntarily chosen not to seek legal counsel concerning this authorization document.