Section I: Client Information

Please provide your identifying information below. This includes your full name, date of birth, and current phone number.

Section II: Authorization for Release/Exchange of Information

Purpose of Disclosure/Exchange:

The purpose of this disclosure is to coordinate housing, medical care, recovery planning, verification of treatment completion, probation/parole compliance, and general case management necessary for my successful residency and recovery at The Trinity House.

Section III: Authorized Recipients

List the individuals or organizations authorized to receive or exchange your information. This may include treatment providers, physicians, probation/parole officers, family members, or other support contacts.

Please complete the sections that apply to you. Leave any categories blank if not applicable.

Section IV: Consent and Signature

1. I understand that my records are protected under federal confidentiality rules (42 CFR Part 2 and HIPAA) and cannot be disclosed without my written consent unless otherwise provided for in the regulations.
2. I understand that this authorization will remain in effect for one (1) year from the date signed, or until the date of my discharge from The Trinity House, whichever is later, unless otherwise revoked.
3. I understand that I have the right to revoke this consent, in writing, at any time, except to the extent that action has already been taken in reliance on it.
4. I understand that the agency/individual receiving this information may not be required to comply with federal confidentiality laws, and the information may be subject to re-disclosure.