By Participating in the program of Pine Grove Behavioral Health or in any aspect of the program, you will be privy to certain confidential information in regard to other program participants.
Any information regarding a person’s presence in this program or items discussed by these persons is strictly confidential and redisclosure of either is prohibited by Federal Regulation (42 CFR Part 2).
I, {name}, have read the above statement and understand that I am responsible for maintaining the confidentiality of all persons participating in this program and for making no further disclosure of information obtained here. I am also aware that certain confidential information of mine may be disclosed or inferred by my participation and I consent to such disclosure evidenced by my participation. If I choose to participate via a video teleconference offered by Pine Grove Behavioral Health & Addiction Services, I have been informed and understand that doing so may pose a potential privacy risk and agree to such risk.