Consent and Acknowledgment Form

     I consent to the use or disclosure of my protected health information by Catholic Charities ("Catholic Charities") to any person or organization for the purposes of carrying out treatment, obtaining payment or conducting certain healthcare operations. Protected health information used or disclosed by Catholic Charities may include HIV/AIDS related information, psychiatric and other mental health information, and drug and alcohol treatment information, as long as such information is used or disclosed in accordance with Connecticut and Federal law, which may require you to provide specific authorization. I understand that information regarding how Catholic Charities will use and disclose my information can be found in Catholic Charities' Notice of Privacy Practices. I understand that this consent is effective for as long as Catholic Charities maintains my protected health information.

By signing below, I understand and acknowledge the following:
· I have read and understand this consent; and
· I have received Catholic Charities' Notice of Privacy Practices currently in effect.

__________________________________________
Print Name of Individual or Personal Representative

__________________________________________    ________
Signature of Individual or Personal Representative              Date

If signed by the individual's representative,
describe the legal authority of the representative to act
on behalf of the individual: ______________________________

Unable to obtain written consent and acknowledgment because:
Individual refused
Emergency treatment situation
Individual not able to sign due to incompetence or other medical reason
Other: ______________________________________