Confidentiality Agreement

for Temporary Members of the Santa Cruz County Integrated Children’s Services Program (SCC ICSP)

The agencies and programs listed on the attached SCC ICSP Release Form have agreed to work together as the Santa Cruz County Integrated Children’s Services Program (SCC ICSP) for the purpose of planning and providing joint services to children and their families.

(write in individual’s or agency’s name) has been authorized to serve as a temporary member of the SCC ICSP Multidisciplinary Team for the case involving (write in minor child’s name) and , the parent or legal guardian of the minor child (write in parent/legal guardian’s name if applicable). As a temporary member of the SCC ICSP Multidisciplinary Team for this client or family, you or your agency are authorized to release or exchange the selected information and records with any or all of the agencies selected on the SCC ICSP Release Form without obtaining an additional release, as long as the exchange of information is necessary and relevant to planning and providing joint services for the client(s) named above.

All SCC ICSP members, including temporary members, must abide by the following minimum confidentiality requirements:

· Confidential client information and records may only be released or exchanged among members of the SCC ICSP after the client or authorized representative has signed the SCC ICSP Release Form, which defines which service providers may share what types of information.

· Client information and records shall be collected and maintained in a manner that provides the maximum protection of client privacy and confidentiality.

· Confidential client information and records obtained through the SCC ICSP shall not be redisclosed to anyone other than representatives of the agencies selected on the Release Form, unless the client or authorized representative has 1) signed a revised SCC ICSP Release Form or 2) signed a release that is separate from the SCC ICSP Release Form.

· All persons who view or access information or records shared through the SCC ICSP are under the same privacy and confidentiality obligations as the staff who disclose or provide the information.

· Information and records obtained through the SCC ICSP may only be shared during the time the client remains a client of at least one of the service providers selected on the Release Form.

· SCC ICSP members, including temporary members, shall have their own written confidentiality policies that meet basic requirements of privacy and confidentiality obligations. SCC ICSP members are responsible for ensuring that the appropriate staff are properly trained and held accountable for carrying out their own confidentiality policies, as well as those governing the SCC ICSP.

I understand that the SCC ICSP is governed by a Memorandum of Understanding, and that I may request and receive a full copy of the signed MOU at any time.

I understand that if I have further questions about the SCC ICSP or this Confidentiality Agreement, I may contact Nicole Young, Service Integration Consultant for First 5 Santa Cruz at (831) 594-1498 or .

I have read, understood and agree to abide by this Confidentiality Agreement.

Printed Name of Representative Name of Organization

Signature of Representative Date

Agreement obtained by (name of SCC ICSP Member Agency)

Temporary SCC ICSP Member Confidentiality Agreement v1.1 Approved 11/05