Multiple Agency Release

Effective date: June 27, 2018

The Multiple Agency Release authorizes Innovative Health Care Concepts to obtain and exchange information and documents pertaining to the following individuals or agencies and the type of information to be released and/or exchanged.

 

Releasing/Exchanging Agency                                           Information to be Released/Exchanged

 

Primary Care Physician………………………………………….. Healthy Connections Referrals, annual medical examination report, any other medical information required for Service Coordination services.

 

 

Social Security Administration………………………………. Information and documents required to assist in maintaining benefits.

 

Idaho Medicaid………………………………………………………..  Information and documents required to assist in maintaining benefits.

 

Liberty Health Care……………………………………………………Information and documents required to coordinate annual eligibility and Support Plan.

 

RISE Services, Inc.……………………………………………………….Information and documents required to coordinate and assist with Certified Family Homes.  Only if applicable.

 

This release is valid for one (1) year from the date of signature. You may limit the information to be released. You have the right to refuse to sign this form. You also have the right to revoke your signature at any time with a written notice to IHCC. No information will be released without your consent.