CONSENT TO DISCLOSE HEALTH RECORDS ATTACHMENT A – Health information may be disclosed for purposes of treatment to the organizations listed The following organizations provide and/or administer Care Management in Monroe County: Allegany County Community Services L. Woerner, Inc. (dba HCR) • • Allegany Associates Liberty Resources • • Anthony L. Jordan Health Corporation Lifespan of Greater Rochester • • Aspire of WNY Lifetime Care • • Baden Street Settlement Livingston County Mental Health • • Baker Hall Inc. dba Baker Victory Services Mary Cariola Children's Center • • Beacon Health Options MC Collaborative • • Berkshire Farm Center for Youth Monroe County Office of Mental Health • • Catholic Charities Community Services Monroe Plan for Medical Care, Inc. • • New Directions Youth & Family Catholic Family Center • • Cayuga County Health Department New York Care Coordination Program, Inc. • • Cayuga Counseling NYSARC Monroe County Chapter • • Cayuga Home for Children dba Cayuga Centers Orleans Co Dept of Mental Health • • Community Care of Rochester, Inc. DBA Visiting Pathways, Inc • • Nurse Signature Care Community Place of Greater Rochester Person Centered Housing Options • • Companion Care of Rochester Rehabilitation Counseling & Assessment • • Services, LLC. Coordinated Care Services, Inc. Rochester Regional Health - • • Unity/GMHC/RMHC Delphi Drug and Alcohol Council Rochester Rehabilitation Center • • DePaul Community Services Rochester Psychiatric Center • • SPCC Society for Prevention East Corporation • • Epilepsy-Pralid, Inc. Steven Schwarzkopf Community Mental • • Health Center Family Services of Chemung County, Inc. Trillium Health • • Finger Lakes Therapy Works United Cerebral of Rochester • • Finger Lakes Addictions Counseling and Referral University of Rochester/Strong Memorial • • (FLACRA) Hospital Finger United Cerebral Palsy dba Venture Forthe, Inc. • • Happiness House Gateway- Longview of Hope • • Genesee Co. Mental Health Wayne ARC • • Glove House County Behavioral Health • • Greater Rochester Health Home Network YWCA • • (GRHHN) HCR Care Management, LLC • Health Homes of Upstate New York (HHUNY) • Hickok Center • Hillside Children’s Center • Huther Doyle Memorial Institute, Inc. • Ibero-American Action League • Jefferson Family Medicine •
CONSENT TO DISCLOSE HEALTH RECORDS – ATTACHMENT A Health information may be disclosed for purposes of treatment to the organizations listed The following organizations provide and/or administer Care Management in Monroe County: • Allegany County Community Services • L. Woerner, Inc. (dba HCR) • Allegany Associates • Liberty Resources • Anthony L. Jordan Health Corporation • Lifespan of Greater Rochester • Aspire of WNY • Lifetime Care • Baden Street Settlement • Livingston County Mental Health • Baker Hall Inc. dba Baker Victory Services • Mary Cariola Children's Center • Beacon Health Options • MC Collaborative • Berkshire Farm Center for Youth • Monroe County Office of Mental Health • Catholic Charities Community Services • Monroe Plan for Medical Care, Inc. • Catholic Family Center • New Directions Youth & Family • Cayuga County Health Department • New York Care Coordination Program, Inc. • Cayuga Counseling • NYSARC Monroe County Chapter • Cayuga Home for Children dba Cayuga Centers • Orleans Co Dept of Mental Health • Community Care of Rochester, Inc. DBA Visiting Nurse Signature Care • Pathways, Inc • Community Place of Greater Rochester • Person Centered Housing Options • Companion Care of Rochester • Rehabilitation Counseling & Assessment Services, LLC. • Coordinated Care Services, Inc. • Rochester Regional Health - Unity/GMHC/RMHC • Delphi Drug and Alcohol Council • Rochester Rehabilitation Center • DePaul Community Services • Rochester Psychiatric Center • East Corporation • SPCC Society for Prevention • Epilepsy-Pralid, Inc. • Steven Schwarzkopf Community Mental Health Center • Family Services of Chemung County, Inc. • Trillium Health • Finger Lakes Therapy Works • United Cerebral of Rochester • Finger Lakes Addictions Counseling and Referral (FLACRA) • University of Rochester/Strong Memorial Hospital • Finger United Cerebral Palsy dba Happiness House • Venture Forthe, Inc. • Gateway- Longview • of Hope • Genesee Co. Mental Health • Wayne ARC • Glove House • County Behavioral Health • Greater Rochester Health Home Network (GRHHN) • YWCA • HCR Care Management, LLC • Health Homes of Upstate New York (HHUNY) • Hickok Center • Hillside Children’s Center • Huther Doyle Memorial Institute, Inc. • Ibero-American Action League • Jefferson Family Medicine
Updated%20GRHHN%20Community%20Referral%20Form%2012.12.16.docx