AVON AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION FOR COLLABORATIVE AGENCIES

AVON AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION FOR COLLABORATIVE AGENCIES
Name of Youth
Name of Youth
First
Last
Address
Address
City
State
Zip
Parent/Legal Guardian
Parent/Legal Guardian
First
Last
Address
Address
City
State
Zip
I HEREBY AUTHORIZE The Avon Youth Assistance Program, Inc. to Exchange information, when needed, with the collaborative agencies and other professionals associated with the AYAP, Inc..

The purpose of disclosure is for coordination of care, programming, and potential data after an event/activity. 

 

This consent is valid until:                 TERMINATION/Completion of Services                                 Date:                                                              

 

   I understand that this information may include information relating to:

  1. Acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) infection;
  2. Substance abuse;
  3. Mental, emotional, or behavioral health;
  4. Medical care;
  5. COVID-19.
  6. Other

 

I understand that I may revoke this authorization at any time by notifying our Advocate or the Director of the Hendricks County Youth Assistance Program, Inc. in writing of my intent to revoke this authorization.  If I do notify the Avon Youth Assistance Program, Inc. in writing, of my intent to revoke this authorization, such revocation will not have any effect on any actions taken by the Avon Youth Assistance Program, Inc. before the revocation.  Written Notification must be delivered to the Avon Youth Assistance Program Advocate or Director.

 

I understand that the Avon Youth Assistance Program will give me a copy of this authorization form after I sign it.  I understand that my records will be professionally and ethically maintained by AYAP, Inc. as provided by the statutes of the State of Indiana, and the Codes of Ethics and Professional Standards of our profession.  Please be aware that once your records are released, this provider can no longer insure their confidentiality.