Care Connect Information Network
Release of Information (ROI)
Purpose of this form: St. Johns County Health and Human Services is a participating provider of vital services (“Participant”)
who is active ServicePoint, a project of the Care Connect Information Network (CCIN) hosted by St. Johns Care Connect, Inc.
ServicePoint participating agencies work together to provide services to persons and families in need. When you request or receive
services, we may collect data about you and your household such as:
Your name, date of birth, Social Security Number, gender, ethnicity, race, veteran status, prior residence and program status.
Your service needs, income, benefits, education, employment, destination, disability, general health, as well as pregnancy,
HIV/AIDS, behavioral health, legal, and domestic violence status, destination.
How will my data be used? The ways in which the Agency may use or disclose your information are discussed in our Notice of
Privacy Practices, which is posted in our reception area; we can direct you to the Notice at your convenience.
How will my data be protected? We enter your data in a computer program that is protected by passwords and encryption
technology. Each Participant and ServicePoint user must sign an agreement to maintain the security and confidentiality of the
information. Any person or Participant that violates the agreement may lose their access rights and be subject to further penalties.
How do I benefit by providing the requested information and sharing it with other agencies? By sharing your information with
other agencies, you may be able to avoid being screened again, get services faster, and minimize how many times you have to t ell
your “story.” You also help agencies document the need for services and demonstrate that funding is needed.
PLEASE PRINT NAME OF INDIVIDUAL AFFECTED BY THIS ROI:
Client Informed Consent/Authorization for Release of Information - By signing this form, I agree that the Agency may disclose
and other participating agencies in the SERVICEPOINT may use the following information for lawful purposes of the agencies that
participate in the SERVICEPOINT and their employees and agents: (please initial & check the applicable boxes if appropriate)
1) I agree to share all of my information with other SERVICEPOINT participating agencies.
2) I agree to share all of my information with other SERVICEPOINT participating agencies, WITH THE
EXCEPTION OF: (Check All That Apply)
HIV/AIDS Information, such as status, diagnostic test results, mode of transmission, sexuality
Domestic Violence Information, such as abuse history, abuser information, trauma information
Behavioral Health Information, such as substance and alcohol abuse and mental illness information
3) I DO NOT agree to share any of my information with other CCIN participating agencies.
I UNDERSTAND THAT:
I am not required to sign this consent and that if I refuse to sign this consent my treatment, payment, or eligibility for benefits will
not be affected. I may also request a copy of this consent after I sign it.
This consent form expires in seven (7) years. I have the right to revoke this consent at any time by writing to the Agency, except
to the extent that the agency has acted in reliance on it. Past information I previously consented to release will not be retrieved
from agencies that received that information. I understand that my revocation must be in writing.
The Agency has posted a Notice of Privacy Practices, and I may request a paper copy of the Notice from the Agency. I
acknowledge that I have been given an opportunity to read and/or request a copy of the Notice and that I have read the Notice.
The Notice describes ways in which my personal information may be used and disclosed within and outside of the Agency. Its
terms may change and I may obtain a copy of the Notice by writing to: CCIN SERVICEPOINT c/o St. Johns Care Connect, 400
Health Park Blvd., St. Augustine, FL 32086.
I understand that neither the Agency, nor the CCIN, can control how another Participant will use or disclose my information that it
receives under this consent. It is possible that the other agency will disclose my information to others, and that the disclosed
information may no longer be protected by federal privacy regulations.
Signature of Individual or Guardian Date Signature of Witness Date
A SEPARATE ROI WILL BE FILLED IN FOR DEPENDANTS IN THE CASE OF A HOUSEHOLD SITUATION.
NO PERSONAL DATA WILL BE COLLECTED UNLESS THIS ROI IS ACKNOWLEDGED AND SIGNED.
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