I understand that information disclosed may be written, verbal or electronic form and may include dates of contact, locations and reasons for contact; medical, prescription, treatment, and outcome information; benefits, financial, and/or asset information; eligibility for services; historical or legal information; and any other private information as needed in relation to providing care management services. I understand that disclosure may also include: psychological/psychiatric information if applicable.

I understand that the purpose of this disclosure is to allow the participating entities (identified above) to access and use the information to establish and maintain continuity of care, to connect accurate and effective resources, and/or to improve their services. I understand that I may refuse to sign this authorization, but my refusal may limit the services available to me through this program.

I understand that the El Paso County Roofing Contractors Association will maintain my confidentiality whenever possible. I understand that there is potential for information disclosed, as a result of this authorization, to be re-disclosed by the recipient and therefore no longer protected by the HIPPA Privacy Regulations. When applicable, an assessment of the minimum necessary amount of information required has been applied to this authorization.

I understand that I may revoke this authorization, at any time, by giving written notice to The El Paso County Roofing Contractors Association. I understand this release will be effective for 12 months following the date of original authorization unless revoked in writing before that time.