Disclosure Form - RP - Downtown Jimmie Hale Mission, Inc.

Disclosure Form – RP

Royal Pines - Consent for Disclosure of Records & Information Form

  • I understand that my records are protected under the Federal Confidentiality Regulations (42 CFR, Part 2) and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it (i.e. probation, parole, etc.) and that in any event this consent expires automatically upon my program graduation, discharge or departure unless otherwise specified below.
  • I, [the above entered name], authorize the staff at Royal Pines to disclose and/or receive information to/from:
  • Please enter the name of the person/organization you wish to receive this information. Please note, you must submit a unique form for each recipient.
  • regarding the completion of the application process for Royal Pines.
  • Email address of the person receiving this form
  • Email address of the person receiving this form.
  • This should be your application date.
    Date Format: MM slash DD slash YYYY
  • The date this information is no longer applicable. If not known or irrelevant, leave blank.
    Date Format: MM slash DD slash YYYY
  • I also agree that I will not take any action, or threat of action, in recourse of a direct, or indirect, nature against these parties for any communication they may engage in with this party in regards to me. I further acknowledge that my rights were fully explained to me and this consent is given of my own free will.
  • I, the undersigned, do understand and accept the above, and acknowledge that typing my name in the field below will serve as my digital signature for this form:
  • Please enter your social security number for additional verification purposes. This information will NOT be shared with the recipient on this form.
  • Date Format: MM slash DD slash YYYY
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