I understand that this release is valid only for the period of one year from the date of my signature and that I may withdraw myconsent at any time. The information to be released has been explained to me and I have had the opportunity to ask questions. I givemy consent voluntarily, without the threat of punishment or promise of reward. I have discussed this release with the person obtainingmy consent and have had my questions fully answered. I understand that I may withdraw my consent at any time without fear ofpunishment.

I give my consent voluntarily, without threat of punishment or promise of reward. I have discussed this release with the person obtaining my consent and have had my questions fully answered. I understand that I may withdraw my consent at any time without fear of punishment.

Please list all medications both over the counter as well as prescription drugs. Please fill in all fields.

NOTE: Please be aware that Triangle does not currently have a nurse on site, so all medications must be self-administered. We cannot assist someone in taking medications. If you have questions about this, please contact Drew Warren at 781-388-4308.

Disability/Disabilities

Instructions: In the table below, mark as follows:

• 1 in the row for primary diagnosis
• 2 for secondary diagnosis
• + for any additional diagnoses.

INSTRUCTIONS:

1. This form must be completed in full, including purpose(s) and expiration.
2. If “Specific Image(s)/Video(s)” is selected, the image(s)/video(s) must be attached. Triangle's team will take care of this.
3. Copies must be distributed as follows:
   - Original: retained by Triangle, Inc. in the individual’s record
   - Copy: provided to the individual and/or guardian/LAR

Click submit at the bottom of the page when you are done.

If you check C., please fill in the event details (must be specific): 

Note: You may check more than one option if you want to authorize (1) additional use and release of future images (A), (2) specific existing images (B), and/or (3) event-only images that will be captured at the event listed above (C) for selected purpose(s) in section III.

1. No requirement to consent. I understand that signing this form is voluntary, and I do not have to sign it to receive services or supports from Triangle, Inc. I understand that no punitive or negative actions will be taken against me if I do not sign this authorization or if I withdraw my consent.
2. No private/sensitive settings or overly intrusive images. This permission does not authorize photography/videography during personal care or in private areas (e.g., bathrooms/bedrooms), or in circumstances that a reasonable person would consider intrusive, private or sensitive.
3. No permission to use images for marketing purposes. This authorization does not permit Error!Reference source not found. to use photographs or video images of me for marketing purposes as defined by the Health Insurance Portability and Accountability Act (“HIPAA”) in 45 CFR 164.501, 164.508(a)(3).
4. No permission to alter images. This authorization does not permit Triangle, Inc. to alter images in any way, including with the use of Artificial Intelligence (“AI”)
5. Redisclosure. I understand that once images/videos or identifying information are shared, recipients may re-disclose them and they may not be protected by privacy laws or regulations.

I understand I may revoke (cancel) this permission at any time by submitting a written request to:

Provider Contact/Office/Title: Triangle, Inc.
Mailing Address: 450 Broadway, Malden, MA 02148
Email: learnmore@triangle-inc.org
Phone: 781 322 0400

• Revocation applies going forward only. It does not apply to uses or disclosures that already occurred before Triangle, Inc. received my written revocation.
• After revocation, Triangle, Inc. will stop future use and will remove images/videos from Triangle, Inc.-controlled platforms where feasible but cannot guarantee removal of copies shared by others.

If signed by Guardian/Legally Authorized Representative (“LAR”)