Client/Resident Name: Date of Birth:

RELEASE OF CONFIDENTIAL INFORMATION

I, , do hereby and authorize Genesis Hopeful Haven to release to and/or obtain from (check appropriate consent)

[Name of Person/Title/Organization]

Genesis Hopeful Haven

[Address/City/State/Zip Code/Telephone Number]

19000 SW 112th Ave, Miami Fl 33157

THE INFORMATION WHICH MAY BE DISCLOSED IS (Check All That May Be Released):

Presence in Treatment (admit/discharge date) Diagnostic Summary Caseworker/Citrus Family Network Medical History and Physical Examination Health Records Diagnosis, Brief Description Progress/Prognosis Multi-Disciplinary Treatment Plan Discharge Summaries /Continuing Care Plan Employment Psychological Evaluation IEP School Records/Grades Teacher Progress notes Foster family Admissions Profile Other:

THIS INFORMATION IS NEEDED FOR THE FOLLOWING PURPOSES

To Provide Ongoing Treatment/Continuing Care
Obtain Insurance/Employment /Government Benefits
To Provide Educational Services
Coordinate Services with Authorized School Officials
To Coordinate Treatment Efforts With Foster Parents / Caseworkers / Concerned Person
To Coordinate Treatment and Continuing Care Efforts With My Employer / Employee Assistance Program.
To Coordinate Vocational Training with Vocational Training Program Officials.
To Allow Insurers To Resolve The Pendency of Claims For Facility/Program Billed Services.
Family Mentor
Other:

The duration of this authorization is until 1 Year Other

I understand that I may revoke this consent at any time by notifying the facility in writing, except to the extent that action has been taken in reliance on my consent. A photocopy of this authorization is to be considered as valid as the originaldocument.