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.