Confidentiality Agreement

I agree to comply with all Federal and State Regulations Governing the privacy, confidentiality, security and availability of protected health information of drug and alcohol clients served by POWER as described in the federal regulations of 42 CFR Part 2 and the Health Insurance Portability & Accountability Act of 1996, and state regulations of Act 63.I agree not to disclose any client or client-identifying information that I may receive, overhear, observe or read in the course of my work with POWER or its clients; or during any authorized visit to a POWER program site. I recognize that the regulations, which are meant to ensure the confidentiality and integrity of individually identifiable client information – past, present and future – are binding, even after the termination of any contracts with POWER and/or the clients it serves. I understand that any unauthorized disclosure of client information is a Federal criminal offense punishable by a fine of not more than $500.00 in the case of the first incident and not more than $5,000.00 in the case of each subsequent offense.

Consent to Release Form

I hereby give to POWER, to its nominees, agents and assigns, my free and unlimited consent and permission, waiving all claims for any compensation by reason thereof or for damages by reason thereof, to use, publish/broadcast, republish/rebroadcast or exhibit in the furtherance of its work, with or without identification of me by name, the work described below:

• Photograph/Video/Likeness
• Public Relations/Education Story
• Original Artwork
• Original Writing