COMMUNITY RELEASE OF INFORMATION

I   First Name*   Last Name*   hereby authorize full communication regarding my progress within Third Party Administrator (TPA) service providers, including but not limited to: my demographic information, justice system involvement, service assessments, services information, and my program outcomes on a need to know basis between the following agencies:

Los Angeles County (JCOD)
Amity Foundation TPA Project
TPA Funded Community-Based Program (CBP) of My Enrollment
Specific Entity/Agency/Business Street Poets Inc.
 
The purpose of this disclosure is to coordinate service provision and all data associated with CFCI funding.
 
I understand that my records are protected under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and HIPAA and cannot be disclosed without my written consent unless otherwise provided for in the regulations.

Expiration if mandated into TPA community services-This consent will expire automatically when there has been a formal and effective termination of services by the program provider.
Expiration if TPA services are voluntary- If I sign up for TPA services without legal mandates to do so, this release will expire thirty days after I complete the TPA funded program and/or services, successfully or unsuccessfully. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it. 

I also understand that recipients of any information disclosed in accordance with Part 2 of Title 42 CFR or HIPAA may re-disclose it only in connection with their official duties.