1. I received a copy of the ADEC "Client Grievance Procedure."
2. I authorize ADEC to use and disclose limited protected health information, without a written
authorization to a family member or other relative, a close personal friend, or any other person
identified by the client, to the extent the protected health information is directly relevant to
the recipient's involvement with the client's care or payment related to the client's treatment,
and to notify the person of the client's location, general condition, or death, if the client has
been informed in advance of the use or disclosure and has the opportunity to agree to, prohibit, or
request restrictions on the use or disclosure; provided that mental health records, drug and
alcohol treatment records and communicable disease records, including HIV/AIDS records, are not
covered by, and may not be disclosed pursuant to this policy.
3. I agree that ADEC may use and/or orally disclose limited protected health information,
excluding mental health records, drug and alcohol treatment records, and communicable disease
records, including HIV/AIDS records, to maintain a facility directory of clients who are present at
the facility.
4. I authorize ADEC to obtain emergency medical care and/or provide basic first aid, including
obtaining emergency response in case of an accident, injury or illness.
5. I agree to participate in services provided virtually with prior consent from the guardian or
person served, when applicable.
6. I authorize ADEC to provide transportation to/from ADEC locations and places within the
community related to the programs of Summer Camp or the needs of the individual served.
7. I agree to comply with the program guidelines and recognize I may voluntarily withdraw from
program services at any time.
IMPORTANT: By signing, I agree to the terms stated above.
