ACCMP Release of Information Form

I understand that the types of information identified in this authorization may be shared, in addition to all exceptions required or allowed by law. This authorization covers all admissions and/or contacts with the above-listed Agencies and individuals and allows a free exchange of this information between and among the Agencies and individuals I have agreed to release and receive information. I understand that the Agencies and/or individuals may need to share information among themselves more than one time and/or with other persons working for the Agencies or service providers.

* Note that Probation shall not release the NCIC/CCIC report, victim location information, copyrighted instruments, or documents the author has indicated in writing should not be released.

The purpose of any disclosure within the Agencies and/or with the individuals will be that the Agencies and/or individuals above will release and receive confidential information only when they need the information to manage, provide, or make service recommendation for me, my child, or other person for whom I am legally responsible (ward). This authorization remains valid unless one of the below applies, whichever is sooner:

• The authorization expires two years from the date I sign the form; or
• When I revoke this authorization by submitting a signed and dated attestation to Adams County Collaborative Management Program Coordinator, c/o Adams County Children & Family Services, 11860 Pecos St. Westminster, CO 80234; or accmp@adamscountyco.gov.

I, (enter name below), hereby revoke any previous authorizations to disclose my protected health information. I understand that this revocation prevents further disclosures or actions and cannot cancel prior actions or disclosures made while this release of information was in effect.

I understand that the information covered by this authorization may be disclosed for data sharing and data collection purposes within the Agencies and may also be used for other legal purposes. Any information shared and gathered by this program prior to the expiration or revocation of this release may continue to be used by the program for statistical and program evaluation purposes.

Authorizations related to Alcohol and Drug Use and Treatment:

I understand that my alcohol and/or drug treatment records are protected by federal law and regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and may also be protected by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 and 164, and cannot be disclosed without my written consent (as given by signature on this form) unless otherwise provided for in the regulations.

I understand that this is a HIPAA-compliant Authorization and as such, the Agencies and/or individuals may not condition treatment, payment, enrollment, or eligibility for benefits on my signing this Authorization. I understand that I can still apply for and receive services on my own, my child’s, or my ward’s behalf without signing this form.

I understand I will be given a copy of this form. A person may use a copy or facsimile (FAX) of this form in place of the original signed authorization form. By signing this Authorization form, I agree that I have read and understand the information on this form. I understand that there is the potential for re-disclosure by the recipient and that it may no longer be protected by the HIPAA Privacy Regulation.