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.

Empowering Potential Housing will obtain informed voluntary consent from Resident before any information is released to agencies or family members.  Empowering Potential Housing has a responsibility for keeping the confidentiality of others in the program. This includes not confirming or denying another’s participation to outside agencies or persons via telephone, in-person, on social media, or in written requests.

As a Resident of a bed in Empowering Potential Housing, you consent and agree to the terms marked above. You will be informed of any changes to this agreement at least a week before they come into effect.

Should the need arise due to your or other resident’s personal safety being at risk, house mom or management may release my personal medical information to the following (type YES or the person's name as applicable):

Text field Emergency medical workers Text fieldParole Officers/Case Managers Text field ALL Emergency contacts Listed on my Demographics/Intake Form

List name of your - Sponsor Text field  AND/OR Therapist(s) Text field

You may NOT release any information to the following individualsParagraph

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.