EIY Release of Info

42 CFR - Part 2 and 45 CFR Parts 160 and 164 RECORDS RELEASE AUTHORIZATION

Name of Client (youth)

gives permission to: Prevention Resources (PR) Early Intervention for Youth Program, To release from my files the following information: General Information. This information is to be released to: School Official(s), School Personnel (ie: SAC, SRO) and Parents/Guardians.

SIGNATURE OF PERSON AUTHORIZED BY LAW TO GIVE CONSENT (parent/guardian)

Clear

DATE

Date

Signature of Client (youth)

Clear

DATE

Date

The within information is disclosed to you from records whose confidentiality is protected by Federal law. Federal Regulations (42 CFR-Part 2 AND 45 CFR Parts 160 & 164) prohibit you from making further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A General Authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.

THIS RELEASE FORM COMPORTS WITH REQUIRMENTS OF HIPAA PRIVACY RULE REGUALTIONS AT 45 CFR PARTS 160 & 164