Name or identification of the person(s) authorized to receive and /or make the use or disclosure: Noble/ Noble Team Representative
Name or identification of the person(s) authorized to release and/or receive the information: Waiver Case Manager, or other members of the PCISP. If applicable: BDDS Service Coordinators, ABA provider, School system and Vocational Rehabilitation
Specific description of the information to be used or disclosed: Progress notes, monthly/ quarterly reports, individual reports, medical information, BDDS incident reports, internal incident reports, behavior plans, data tracking and information related to services
The information may be used or disclosed for these purposes: To complete the Noble intake file and review for the service requested
I understand that the information used or disclosed may be subject to redisclosure by the person(s) or class of persons receiving it and is no longer protected by federal privacy regulations. I may revoke this authorization by notifying Noble, 7701 E. 21st St., Indianapolis, IN 46219, in writing of my desire to revoke it. However, if I revoke this authorization, it will not have any effect on actions taken by Noble in reliance on this authorization. A copy of this completed and signed form will be provided to me upon request.
This authorization will expire one year from the date below: