Innovative Change Makers (ICM)
Authorization for Release and Exchange of Information
By participating in services provided by Innovative Change Makers (ICM), I authorize ICM to obtain, use, and exchange information as necessary to coordinate services, make referrals, evaluate program outcomes, and comply with grant and funding requirements.
This authorization applies to participation in all ICM programs and services, including but not limited to mentoring, case management, resource navigation, behavioral health referrals, therapy services, substance use prevention and intervention services, workshops, community events, recreational activities, educational and career programs, support groups, and other services provided directly by or in partnership with ICM.
Information that may be shared includes basic identifying information, program enrollment and attendance, referral information, assessments, surveys, participation, progress toward goals, services received, and other information necessary to coordinate care, evaluate program effectiveness, and fulfill contractual or grant reporting requirements. Information may be shared only with authorized funding agencies, grant administrators, licensed service providers, healthcare and behavioral health providers, schools, community partners, evaluation organizations, and other agencies directly involved in providing or supporting services.
Innovative Change Makers (ICM) is committed to protecting the privacy and confidentiality of all participants. All personal information and records, including information related to events attended, services received, therapy services, referrals, assessments, and other protected information, are maintained securely and handled in accordance with applicable federal and state confidentiality and privacy laws. Information is shared only when necessary for service coordination, program operations, or funding compliance and is never sold or released for marketing or unauthorized purposes.
Participants may request additional information regarding ICM's privacy practices or revoke this authorization in writing at any time, except to the extent that information has already been released or used in reliance on this authorization as permitted by law.