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Community Connect Authorization to Release Information
Our agency participates in the Community Connect case management system. Connect is a shared system for service providers in the community designed to help people manage their support services, learn about benefits they may qualify for, and connect with agency staff for assistance in enrollment or eligibility. Connect is managed by the Boulder County Department of Housing & Human Services.
By signing this authorization form, you are agreeing to allow Connect Partner Agencies to share your information for the purpose of coordinating resources and services on your behalf.
Who May Share My Information?
Partner Agencies include county human and social services agencies, non-profit community organizations, and other care coordination entities that you are receiving or may be eligible to receive services from. A current list of Connect Partner Agencies is provided with this form and is available at https://www.bouldercountyconnect.org/apex/ConnectPartnerAgencies
Additional Partner Agencies may join the Connect network after I have signed this authorization, and I agree that later added Partner Agencies may access my information for the purposes described herein.
How Will My Information be Used and Disclosed?
Your information may be exchanged by Connect Partner Agencies for the purpose of coordinating resources and services on your behalf, including benefit determination and case management. Only information that is necessary or appropriate to manage resource access, benefit determination, and case coordination will be shared.
What Information May be Shared?
Partner Agencies may exchange the following types of information (as applicable):
• Name, date of birth, demographic and contact information
• Program enrollment and benefits/services received
• Case notes, assessments and planning activities
• Employment and income information
• Photo ID (e.g., driver's license, passport, military or other government issued ID) and/or birth bertificate (for identity verification)
• Basic household information, including any of the above information about your minor children
BY AGREEING BELOW, I UNDERSTAND THAT:
> I am not required to sign this authorization in order to apply for or receive benefits or services from Partner Agencies.
All Partner Agencies covered by this authorization are contractually required to maintain the confidentiality of my information. Partner Agencies must follow all federal and state laws and regulations that apply to release of my information.
> Partner Agencies may use anonymized (non-identifying) data for program evaluation, assessment, and other legal purposes.
> I may revoke this authorization at any time, except to the extent that a Partner Agency has acted in reliance upon it, by sending written notification to any Partner Agency.
> I may acquire a copy of this release at my request.
> Expiration of Authorization: Unless terminated earlier by me, this authorization will expire one (1) year from the date signed.
By agreeing below, I certify that I have read and understand the content of this form.
Select your meat options using a "ranked choice". We will meet your request with our inventory moving down your list. For example, if your #1 choice is beef and #2 is chicken, we will give you beef unless we are out, in which case we'll move to your next choice and give you chicken. Please rank your choices all the way from #1 to #5. If you don't have 5 choices, you can select "none".