Intake- Authorization To Release Information

Intake Authorization To Release Information
Individual Name

First Name of the individual receiving support from NobleLast Name
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.

Specific description of the information to be used or disclosed: PCISP, BSP, HRP/ Wellness Plan, 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:
Date

MonthDayYear
Date
Does this individual have a legal guardian?

YesNo
I herby authorize the release or disclosure of protected health information about me as described.
Guardian Name:

First NameLast Name
Guardian Signature:

Clear
Signature of the individual:

Clear
If you would like a copy of the completed authorization please enter your email address:
example@example.com
Noble Staff you are working with on Intake:
Primary Caregiver name:

First NameLast Name
Primary Caregiver signature:

Clear
Date

MonthDayYear
Date
Should be Empty:

Intake Authorization To Release Information