FreedomWorks Post Prison Outreach

3D"FreedomWorks

FreedomWorks

Release of Information Authorizatio= n Form

Applicant’s full name_____________________= ___________________________

        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;     First           =             &nb= sp;      Middle Int           =             &nb= sp;   Last

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Date of birth______/______/______        =           SSN: _____-_____-_____

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I ______________________________________authorize FreedomWorks staff the righ= t to

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speak to individuals and/or agencies regarding my acceptance to reside and/or to maintain residency in the FreedomWorks Discipleship Residential Program.

I also authorize Freedomworks staff the right to review and/or to receive mental heath, physical heath and probation/parole records upon requ= est.

I understand that:

1. <= span style=3D'mso-tab-count:1'>        &= nbsp;   My health information is protected by Federal Confidentially Rules (42 CFR Par= t 2; and/or HIPAA, 45 CFR) and state privacy laws, and disclosure is allowed only with my authorization except in limited circumstances as outlined in Freedomworks policies. I also understand that I have the right to inspect a= nd receive a copy of my treatment records that may be disclosed to others as provided under applicable state and federal laws.

2. <= span style=3D'mso-tab-count:1'>        &= nbsp;   I can revoke this authorization in writing at any time by providing a written notification to Freedomworks, except to the extent that action has been tak= en in reliance on it. This authorization will expire two years form the date I sign, unless I request and earlier revocation in writ= ing.

3. <= span style=3D'mso-tab-count:1'>        &= nbsp;   Communications resulting from this authorization will reveal that I have received or have attempted to receive services at Freedomworks Post Prison Outreach.

4. <= span style=3D'mso-tab-count:1'>        &= nbsp;   Federal confidentiality regulations prohibit redisclosure of information.

5.  &n= bsp;          While living in FreedomWorks Residential Program= I can not revoke the authorization release of information. I can however revoke this authoriz= ation upon leaving FreedomWorks.

Applicants Si= gnature: ______________________________________ Date: ____/_____/_____

FreedomWorks = Staff: ______________________________________ Date: ____/_____/_____

I chose to revoke= this authorization.

Participant Signature: ______________________________________ Date: ____/____/_____