CONFIDENTIAL INFORMATION CONSENT Judah Ministries Inc. Please enable JavaScript in your browser to complete this form.I, *do hereby consent and authorize Judah Ministries Inc as indicated below to obtain from and release to:Name of person / Title / Organization *Relationship to ClientAddressAddress Line 1City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeThe following information pertaining to:Name * Notes Name/Signature Layout THE INFORMATION WHICH MAY BE DISCLOSED IS:Presence in Elevation ProgramObtainReleaseProgress NotesObtainReleaseDischarge Summary/Continuing care planObtainReleaseIntake AssessmentObtainReleaseMonthly ReportsObtainReleaseTHIS INFORMATION IS NEEDED FOR THE FOLLOWING PURPOSESTo provide ongoing wrap-around services / continuing careTo provide educational servicesCoordinate services with authorized school officials, if needed.To coordinate educational planning and re-entry services and programmingTo enable judges, attorney, probation / parole officers to support goals or make legal decisions on my behalfI UNDERSTAND THAT I NEED TO CONSENT TO RELEASE OF INFORMATION IN ORDER TO OBTAIN SERVICES. I CHOOSE TO DO SO WILLINGLY AND VOLUNTARILY FOR THE PURPOSE SPECIFIED ABOVE. I UNDERSTAND THAT I MAY REVOKE THIS CONSENT AT ANY TIME BY NOTIFYING THE CASE MANAGER IN WRITING, EXCEPT TO THE EXTENT THAT ACTION HAS BEEN TAKEN IN RELIANCE ON MY CONSENT.Signature of Client *Signature DateSignature of Case Manager *Signature DateName/Signature of Witness *Signature DateNOTICE TO RECIPIENT OF INFORMATION: Information has been disclosed to you from records whose confidentiality is protected by Federal or Indiana laws and regulations. Such laws prohibit you from making any further disclosure of the information without specific written consent of the person to whom the information pertains or as otherwise permitted by such laws and regulations. A general authorization for release of medical or other information is not sufficient for this purpose. The Federal and Indiana laws and regulations restrict any use of the information to criminally investigate or prosecute any patient.Submit
