S&H Youth and Adult Services, Inc.

714 S Main St Salisbury NC 28144 5736 N Tryon Charlotte NC 28213

SHYAS.COM | 866-495-3651 I704-353-7901

Consent to Release or Exchange of Consumer Information

Name, Address, & Phone Number of Agency, Organization or

Name, Address, & Phone Number of Agency, Organization or

Individual Releasing information (i.e. primary care, psychiatrist, previous Treatment provider, natural supports, school)

S&H Youth and Adult Services, Inc. Inc.

714 South Main Street Suite 208

I understand that the information released may include information regarding HIV/AIDS information. I consent to the above-named agencies,organization or individuals to release, exchange, and/or communicate with one another the information that is listed below for

the purposes of Coordination of Care

Treatment report from other agencies / persons (specify):

Client must initial if any of the above data contains substance abuse information:

I understand that my records are protected under the federal regulations governing the confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulation. I understand that if my record

contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure will include that information. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or my eligibility for benefits; however, if a service is requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is not given. If treatment is research-related, treatment may be denied if authorization is not given.

theextentthat the agency which is to release information has already taken action in reliance on it. If not revoked sooner, this consent will terminate upon(mm/dd/yy) (not to exceed one year from date of signature) or specified event or condition which may include

termination of services, of whichever is earlier.

Consumer or Legally Responsible Person Incase of minor receiving substance related services, the minor must always sign the Consent for Release of Information, and when applicable, the legally responsible person

S&H Youth and Adult Services, Inc.

714 S Main St Salisbury NC 28144 5736 N Tryon Charlotte NC 28213

SHYAS.COM | 866-495-3651 I704-353-7901

Consent to Release or Exchange of Consumer Information

Name, Address, & Phone Number of Agency, Organization or

Name, Address, & Phone Number of Agency, Organization or

Individual Releasing information (i.e. primary care, psychiatrist, previous Treatment provider, natural supports, school)

S&H Youth and Adult Services, Inc. Inc.

714 South Main Street Suite 208

I understand that the information released may include information regarding HIV/AIDS information. I consent to the above-named agencies,organization or individuals to release, exchange, and/or communicate with one another the information that is listed below for

the purposes of Coordination of Care

Treatment report from other agencies / persons (specify):

Client must initial if any of the above data contains substance abuse information:

I understand that my records are protected under the federal regulations governing the confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulation. I understand that if my record

contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure will include that information. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or my eligibility for benefits; however, if a service is requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is not given. If treatment is research-related, treatment may be denied if authorization is not given.

theextentthat the agency which is to release information has already taken action in reliance on it. If not revoked sooner, this consent will terminate upon(mm/dd/yy) (not to exceed one year from date of signature) or specified event or condition which may include

termination of services, of whichever is earlier.

Consumer or Legally Responsible Person Incase of minor receiving substance related services, the minor must always sign the Consent for Release of Information, and when applicable, the legally responsible person

S&H Youth and Adult Services, Inc.

714 S Main St Salisbury NC 28144 5736 N Tryon Charlotte NC 28213

SHYAS.COM | 866-495-3651 I704-353-7901

Consent to Release or Exchange of Consumer Information

Name, Address, & Phone Number of Agency, Organization or

Name, Address, & Phone Number of Agency, Organization or

Individual Releasing information (i.e. primary care, psychiatrist, previous Treatment provider, natural supports, school)

S&H Youth and Adult Services, Inc. Inc.

714 South Main Street Suite 208

I understand that the information released may include information regarding HIV/AIDS information. I consent to the above-named agencies,organization or individuals to release, exchange, and/or communicate with one another the information that is listed below for

the purposes of Coordination of Care

Treatment report from other agencies / persons (specify):

Client must initial if any of the above data contains substance abuse information:

I understand that my records are protected under the federal regulations governing the confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulation. I understand that if my record

contains information relating to HIV infection, AIDS or AIDS-related conditions, alcohol abuse, drug abuse, psychological or psychiatric conditions, or genetic testing this disclosure will include that information. I also understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to obtain treatment, payment for services, or my eligibility for benefits; however, if a service is requested by a non-treatment provider (e.g., insurance company) for the sole purpose of creating health information (e.g., physical exam), service may be denied if authorization is not given. If treatment is research-related, treatment may be denied if authorization is not given.

theextentthat the agency which is to release information has already taken action in reliance on it. If not revoked sooner, this consent will terminate upon(mm/dd/yy) (not to exceed one year from date of signature) or specified event or condition which may include

termination of services, of whichever is earlier.

Consumer or Legally Responsible Person Incase of minor receiving substance related services, the minor must always sign the Consent for Release of Information, and when applicable, the legally responsible person