Authorization to Release/Exchange Information Form

This form allows the Member to authorize the Kindness Initiative to release or exchange personal information, with qualified Service Providers. As a Member, you can choose what information you would like us to share. This form eliminates the the burden of your filling out release forms repeatedly, for multiple Service Providers, and may speed up the process of obtaining needed services. You choose what information you authorize the Kindness Initiative to disclose, to whom, and for how long. You are not required to complete this form, and may wait to complete it until it is needed.

4950 Murphy Canyon, San Diego, CA 92123 Tel: 858-216-1666

First Name

Second Name

Phone

Kindness Initiative Member (KIM) Membership Number

Date of Birth

I authorize The Kindness Initiative (hereinafter "TKI") to disclose/exchange protected all health information and records obtained in the course of receiving various types of assistance from TKI or its service partners, without limitation, except for the following specific types of information:

Excluded information which is not authorized for release (Check all that apply)

AssessmentServices PlanningDates of servicesGeneral DemographicsResource coordinationMental Health recordsOther (please specify in box above)**No limitations of disclosure

Name of Organization

Address of Organization

Phone

RIGHTS

I understand my records are protected under federal regulations and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I can refuse to sign this authorization. I understand that I may inspect or obtain a copy of the information used or disclosed, as provided in 45 Code of Federal Regulations section 164.524. I understand that I have the right to revoke this authorization at any time. I understand that the revocation will not apply to information that has already been released based on this authorization. Any revocation or modification of this authorization must be in writing and received by Provider at 4950 Murphy Canyon Rd., San Diego, CA92123.

EXPIRATION: This authorization will remain valid through:

Date of signature

By sending this form - I acknowledge that the above information is true and correct and that my signature is valid. I also acknowledge that any revocation or modification of this authorization must be in writing and received by Provider at 4950 Murphy Canyon Rd., San Diego, CA 92123.