Authorization to Release Information
The Transcend STEM Education Program is designed to partner with other organizations which assist families experiencing a housing crisis, unemployment, career changes, needing education or other assistance. This authorization is to permit Transcend STEM Education and those organizations to share client information in order to collaborate on services and promote stability. By signing below you allow Transcend STEM Education to share (check ALL that apply)
Information to Be Released: Only authorized personnel will share client information needed for service delivery, program eligibility, to track demographic trends, service patterns and the client outcomes achieved. Non-personally identifying information may also be used for the purposes of research and reporting to other services agencies, current and potential program funding sources, and other programs offered by.
For the Purpose of: (a) providing coordinated housing, medical, social, psychological, and other services to me, (b) evaluating the outcomes related to service delivery, and (c) to improve coordination of services to assist individuals and families experiencing a crisis, and (d) to identify barriers and service gaps that block the path out of poverty. In the event of the publication of the results of the program, my identity will be kept confidential, although information about my circumstances may be discussed.
Right to Revoke: This authorization is subject to revocation at any time except to the extent that the agencies which are to make the disclosures have already taken action in reliance on those disclosures.
Potential Re-disclosure: In understand that information that I authorize to be disclosed may be re-disclosed and not subject to medical privacy regulations. However, federal confidentiality rules (42 CFR, part 2) prohibit recipients from making any further disclosure of alcohol and substance abuse records unless further disclosure is expressly permitted by written consent of the person to whom they pertain or if disclosure is otherwise permitted by 42 CFR, part 2. The Federal rules restrict any use of the information to criminally investigate or prosecute and alcohol or drug abuse client.
By signing below, I authorize Transcend STEM Education to share information as it relates to my specific needs.