Individual Intake Resources Information Release Information Release "*" indicates required fields Name* First Last The following information may be exchanged* Adult Services Children Service Comm. Living Services Consultations D & E Discharge Summary Exit Checklist Financial Information Individualized Support Plan (ISP) Medical Information Occupational Therapy Records Personal Information Physical Therapy Records Psychological Evaluation School Records Speech Treatment Plans Work Evaluation Work Related Information Other Define 'Other' information to be exchanged*Dates of Services The need for this release of information includes the following* Coordination of Services Eligibility Determination Job Development Job Retention Legal Mutual Consent Ongoing Care/Treatment Other Define 'Other' needs*Transmission via Email* I agreeI consent to allow transmission via e-mail as determined necessary or appropriate by CDC Resources. I understand that while CDC Resources will take every precaution to protect the privacy of my information, that transmission via e-mail is not always secure. I understand that my records are protected under Indiana and Federal confidentiality regulations. I understand that this consent is subject to revocation by me at any time except to the extent that action has already been taken. This consent will automatically expire at the end of 365 days from the date signed.Disclosure Statement* I agreeI hereby authorize Lirio Resources to share protected health information and identification including, but not limited to: name, address, phone number, social security number, date of birth, Medicaid number, and billing information to any Business Associate of Lirio Resources as deemed necessary for the coordination of my care. I understand Lirio Resources abides by the Health Information Portability Accountability Act of 1996 to maintain compliance and assures that only the minimum necessary information to accomplish the intended purpose of the use, disclosure, or request shall be shared. Lirio Resources follows the laws that tell us when we must share health information and when we can share health information without your permission. Lirio Resources will share information: • As required by law • To public health authorities to report such things as contagious diseases and for birth, death and immunization records. • To the police or military as requested by law • For court and administrative proceedings • To health oversight authorities to see government programs are being conducted properly. • Funeral directors or coroners • For organ donation purposes • To family, relative, or others who help in your care Your rights: • You have the right to request Lirio Resources limit the information they share about you, understanding Lirio Resources must share information deemed necessary to provide quality care. • You have the right to receive your information from Lirio Resources privately and provided to the address and in the format of your choice. • You have the right to inspect and copy your information that Lirio Resources has. • You have the right to receive a list of the parties outside Lirio Resources that have received your information.Signature of Individual Served* Date* MM slash DD slash YYYY Signature of Parent/Legal Guardian/Advocate/Witness/Spouse* Date* MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged. Forms and Policies Individual Information and Intake Form Emergency Medical Information Information Release Policy On Resolving Consumer Complaints