Resident Confidentiality/Release of Information Agreement

Empowering Potential Housing and its operations or house leader(s) will respect your privacy.  Any information concerning Resident, potential Resident, and visitors will be treated with the utmost respect. We will regularly review confidentiality requirements to comply with both CCAPP (California Consortium of Addition Programs and Professionals) standards and state and federal confidentiality laws.

All data collected that’s shared with governing agencies with protect individual identities. This data will only be used to improve the quality of services.  Empowering Potential Housing will ensure the safety of records. Personal information will be protected by reasonable security safeguards against loss or theft, as well as unauthorized access, disclosure, copying, use or alteration.

Confidentiality may be broken without consent only in extenuating circumstances, such as personal safety is at risk, child or elderly abuse is suspected, or if a court order is received.  Outside of these circumstances, identifying information will never be sold, lent, or given to third parties without resident consent.

By signing below Empowering Potential Housing has consent from Resident to release information to cooperating agencies and medical providers.

As a Resident of a bed at Empowering Potential Housing, you consent and agree to the terms all terms of the confidentiality and release of information:

Print YOUR Name: Client first name  Client last name

Signature : SignatureDate: Date

This Release of Information is valid for 24 months from the date of this signing above – if anything changes it is the resident’s obligation to inform and revise this document.

You may NOT release any information to the following individuals:   Paragraph