Release of Information

MULTI-PARTY AUTHORIZATION FOR USE AND DISCLOSURE OF PERSONAL DATA

I authorize Connecting Point and its Referral Partners, including those listed on its website, to create a record and share my present, past and future, personal, financial, health, health insurance, disability, employment, housing status and other information about me or my family or household (Personal Data) with each other and with my Representative. The information shared will be limited to that information necessary to provide services to me such as to make a referral, to assess needs, coordinate care, qualify for benefits, assist with program enrollment and other lawful purposes described in the Notice of Privacy Practices posted at http://www.connectingpoint.org.

I understand this Authorization covers, without limitation, all information shared by me, my family, household members, personal representatives or other persons involved in my care with Connecting Point or its Referral Partners and that information disclosed pursuant to this Authorization may be re-disclosed and, in some cases, such as when protected health information is shared, it may no longer be protected under HIPAA and other applicable privacy laws.

I understand; I may get a copy or revoke this Authorization at any time by sending an email to [email protected] or by written request sent to 208 Sutton Way, Grass Valley, CA 95945 or by contacting our Contact Center at 211 or 1-833-DIAL211. Revocation will not affect any information previously disclosed in reliance on this Authorization. Revocation or my refusal to sign this Authorization may limit Connecting Point’s ability to make referrals, coordinate care or provide me with other programs and services. Unless I specify a different date, this Authorization will expire Seven (7) Years from the Effective Date indicated below.