Authorization to Disclose

Client # HEALTH INFORMATION

AUTHORIZATION TO DISCLOSE

I, ______born on this date ______(Name of person whose information is being requested) authorize HowardCenter to disclose to members of the Vermont and national community the following health information (medical, developmental, mental health, substance abuse, etc.) that I’ve provided:

___ Photograph or Movie describing my experiences

___ Quote that I provided regarding my experiences

The purpose of this disclosure is to develop best practice guidelines to promote successful transition to adult healthcare, post- secondary education, work and independence for youth and adults with Autism Spectrum Disorder. I understand that my information will become part of the Vermont Transition Guide for Youth with Autism and be available online and in hard copy.

This marketing does involve direct remuneration to the agency from the State of Vermont through a federal grant. HowardCenter has been contracted to develop the guidelines noted below.

I understand that federal regulations (42 CFR part 2) prohibit the redisclosure of drug & alcohol treatment information without my written consent or as allowed by the regulations. I understand that under Vermont statute, my health information can only be disclosed with my authorization or as mandated by an express provision of law. For disclosures of information made to organizations outside of the State of Vermont, all other health information used or disclosed pursuant to the authorization may be subject to redisclosure by the recipient and no longer protected by this rule (Privacy Standards of the Health Insurance Portability and Accountability Act of 1996).

I understand that my treatment/support is not conditioned upon authorizing this disclosure. I understand I may revoke this authorization at any time except to the extent that HowardCenter or the State of Vermont has already acted in reliance on it. In general, revocation should be submitted in writing and sent to HowardCenter at the address below. I understand that once my information and image are posted on the website and distributed in print it will not be possible to remove it from the public domain (your information would be removed from the website and future publications if you decided to revoke this authorization).

Date or event upon which this authorization will expire: termination of the guidelines and/or website.

Client's Signature: ______Date: ______

Parent/Guardian Or Legal Representative's Signature: ______Date: ______

Witness' Signature: ______Date: ______

I hereby revoke this authorization on ______(date) at ______(time). Do not release any further information under this authorization.

Signature:

HowardCenter Health Information Department 300 Flynn Ave Burlington, VT 05401 Fax: 802-488-6131