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.

I hereby give Street Poets Inc the right and permission to copyright, publish, reproduce and or use the work (i.e. art, writing, videos) I produce during my participation in programming and workshops facilitated by Street Poets Inc staff and or consultants. By agreeing to the above, I also give Street Poets Inc permission to use my name, photo and biography that I have written or recorded for lawful use such as the production of newsletters, brochures, webpage or for future workshop samples as well as for fundraising purposes. I understand some Street Poets Inc programs may be funded by governmental agencies, like the Los Angeles County Probation Department. To the extent that Street Poets Inc is required to share information collected from participants in such programs, including data collected via surveys or questionnaires, I understand that Street Poets Inc will take the necessary steps to ensure that all information provided will be kept confidential and that my personally identifiable information will not be shared with or made available to such governmental agencies. I waive all rights to any further compensation should Street Poets Inc use my finished product for future use while I am a Street Poets Inc member, I am a Street Poets Inc alum or should I have voluntarily left or been asked to leave the program for any reason.