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AGAPE Behavioral Health

CONSENT FOR THE MUTUAL RELASE OF CONFIDENTIAL

CRIMINAL JUSTICE INFORMATION

I, ____Benny Palma_______________ authorize AGAPE Behavioral Health to disclose (First and last name of patientto ___!oseph Beranti________ the follo"in# information$

I here%y re&uest and authorize that the follo"in# types of information may released'

Initial Assessment ummary of )reatment Pro#ress *otes

)u%erculosis )est Insurance Billin# Information +eely *otes

)he purpose of the disclosure authorized in this consent is to'

Allow confidential information to be disclosed to a third party. The results of the treatment

summary will be allowed to dispensed to an outside party.

)his authorization e-pires one (. year from the date I si#n it, "hichever is first$ If dischar#efrom the pro#ram occurs %efore the release e-pires, information may still %e shared up to thedate of e-piration$ I understand that this authorization cannot %e revoed %y me until one of thefollo"in# events occur'

)here has %een a formal and effective termination or revocation of my release fromconfinement, pro%ation, or parole, or other proceedin# under "hich I "as mandated intotreatment$

I understand that confidentiality of my alcohol and dru# service/ records are protected under thefederal re#ulations #overnin# 0onfidentiality of Alcohol and 1ru# A%use Patient 2ecords 34 02FPart 4, and )he Health Insurance Porta%ility and Accounta%ility Act of .556 (7HIPPA8, 39 0F2

parts .6: ; .63, and cannot %e disclosed "ithout my "ritten consent unless other"ise providedfor in the re#ulations$ I also understand that I may revoe this consent in "ritin# at any timee-cept to the e-tent that action has %een taen in reliance on it, and that in any event thisconsent e-pires automatically as follo"s'

If past criminal activity will indict the client currently.

I understand that #enerally AGAPE Behavioral Health may not condition my treatment on"hether I si#n a consent form , %ut in certain limited circumstances I may %e denied treatmentif I do not si#n a consent form$

1ate' _________________ ______________________________________ (i#nature of 0lient

______________________________________ (i#nature of +itness

7/23/2019 Criminal Justice Release of Authorization

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0lient *ame'