Care Coordination Program

Welcome!

Thank you for participating in our program. We believe that parents are the best source of information about their child and are excited to offer the opportunity to learn more about your child's unique development and provide tools and resources to help your child learn and grow. 

In order to participate, CCRC requests your authorization to share information. 

Please click Continue to read and sign the authorization form. 

I agree to allow Child Care Resource Center to share information collected about me and my child(ren) as it relates to the Help Me Grow Inland Empire (HMGIE) Care Coordination Program with Loma Linda University Children’s Hospital and First 5 San Bernardino (First 5 SB). Information collected by CCRC will be utilized by Loma Linda University Children’s Hospital to assess the quality of services delivered, make program improvements, and determine the overall effectiveness of the CCRC HMGIE Care Coordination Program.  

I understand the information shared may include information related to:

• Demographic information (e.g., address, gender, ethnicity, primary language)
• Services (e.g., referrals made, types and dates of services provided, result of services)
• Developmental information (e.g., screening, assessments and/or services)
• Medical Records (e.g., health/dental care, childbirth information)

I understand that:

• I will not be identified in the reporting of Program evaluation results in any way to First 5 SB. Reports prepared for First 5 SB related to CCRC HMGIE Care Coordination services will NOT identify me by name or include other protected health information such as my date of birth, medical record number, health insurance information or social security number, except that my zip code may be used with other participant zip code data for purposes of creating graphs depicting the communities in which the Program participants reside. I understand that my information will be aggregated with other F5 HMGIE Program data. I further understand that there is a potential for redisclosure of protected health information shared pursuant to this authorization by First 5 SB.
• Providing my personal information is voluntary and that it is my right to refuse to answer a question without any consequences to receiving services under the Program. I further understand that I have the right to request restrictions on uses and disclosures of health information and my participation in the Program cannot be conditioned on the signing of this Authorization.
• CCRC, Loma Linda University Children’s Hospital, and F5 SB staff are subject to follow guidelines set forth by the Health Insurance Portability and Accountability Act (HIPAA) and California Health and Safety Codes 130200 (AB211) and 1280.15 (SB541) which require the protection and handling of protected health information. All client records are confidential and are protected in a HIPAA compliant, Electronic Health Records System (EHRS) that can only be accessed by authorized CCRC HMGIE Care Coordination Staff.
• There are legal exceptions to client confidentiality. If there is a reason to believe there is danger to self and/or others, including suspicion of child abuse (sexual, physical, emotional, general neglect) confidentiality will be waived and minimally necessary information will be disclosed to ensure the safety of all involved.
• This authorization shall remain in effect until one (1) year from the date this form is signed. I may also revoke this authorization to share my information at any time by submitting a written request to Child Care Resource Center: Family Well-Being Manager, 1111 E. Mill Street, San Bernardino, CA 92408.
• This authorization does not include the sharing of CCRC HMGIE Care Coordination service notes, nor does it allow me to be put on a marketing list or allow for the sale of my protected health information. This information can only be shared if I sign a separate authorization to do so.
• I understand that I have a right to receive a copy of this authorization.

I have read and understand the terms of this Authorization, and I have had the opportunity to ask questions about the use and disclosure of my and my child's health information. By my signature below, I hereby, knowingly, and voluntarily, authorize CCRC to use and disclose my and my child's health information in the manner described in this form.

Child Information *

This program is for children ages 0-5. Please indicate the number of children participating in this program and provide each child's name and date of birth.