TBRI Registration Form

By submitting this registration I authorize and agree to the following:
I authorize COBYS Family Services to provide demographic information (i.e. race, age, etc.) to funding sources and release attendance and/or participation information upon to the funding source and the participant’s referral source.
I agree and understand COBYS Family Services provides educators. Therefore, I will not ask anyone from COBYS to be called for testimony for any future proceedings. COBYS will acknowledge attendance to classes but no other information.
I understand that COBYS staff are mandated reporters, and are required by law to report to the appropriate agency when there is reasonable cause to suspect child abuse.

Our funding source requires the following Authorization prior to attending this class.

By giving my consent electronically to this Authorization I hereby voluntarily permit the use or disclosure by Lancaster County Children and Youth Service Agency of protected health information (PHI) pertaining to me, my health, or my healthcare (including paper, oral, and electronic interchange).
The following individual or organization is authorized to make the disclosure:
COBYS FAMILY SERVICES
* The type and amount of information to be used or disclosed is as follows:
For attendance purposes only.

Purpose for the Disclosure: (The information to be used or disclosed is to . . . )
Obtain or coordinate services and supports relevant to my well being and health by Lancaster County Children and Youth Agency. How we use and disclose your protected health information is described in detail in the Notice of Privacy Practices. I understand that authorization the disclosure of health information is voluntary.

Persons Authorized to Use or Disclosed: (The person(s) authorized to make the requested use or disclosure):
Staff employed or contracted by Lancaster County Children and Youth Agency.

Persons Permitted to Receive the Information: (The person(s) to whom the use or disclosure may be made):
Persons or business providers Lancaster County or the Commonwealth of Pennsylvania have entered into service contract(s) or HIPAA Business Associate Agreements with (if so, will be noted here).
Expiration Date or Event: This authorization shall remain in force with Lancaster County Children and Youth Agency for 6 months, unless a different event or date is specified here.
Right to Revoke:
You have the right to revoke this Authorization at any time and may do so by contacting your assigned Caseworker in writing. If we have already used or disclosed your protected health information before receiving your revocation, you understand that we cannot take back those uses or disclosures.
Information may be re-disclosed: Information used or disclosed pursuant to the Authorization may be subject to re-disclosure by the recipient and may no longer be subject to privacy protections provided by law.