The purpose of disclosure is for coordination of care, programming, and potential data after an event/activity.
This consent is valid for until: TERMINATION/Completion of Services.
I understand that this information may include information relating to:
a. Mental, emotional, or behavioral health;
b. Medical care;
c. Attendance, behaviors;
I understand that I may revoke this authorization at any time by notifying our Advocate or the Director of the Plainfield Youth Assistance Program, Inc. in writing of my intent to revoke this authorization. If I do notify the Plainfield Youth Assistance Program, Inc. in writing, of my intent to revoke this authorization, such revocation will not have any effect on
any actions taken by the Plainfield Youth Assistance Program, Inc. before the revocation. Written Notification must be
delivered to the Plainfield Youth Assistance Program Advocate or Director.
I understand that the Plainfield Youth Assistance Program will give me a copy of this authorization form after I sign it.
I understand that my records will be professionally and ethically maintained by PYAP, Inc. as provided by the statutes of
the State of Indiana, and the Codes of Ethics and Professional Standards of our profession. Please be aware that once
your records are released, this provider can no longer insure their confidentiality.