Confirmation of patient/client consent to disclose medical and identifying information including address:

The Breathe Easy at Home Program (BEAH) is designed to help tenants with asthma secure safe housing conditions by means of inspection and state sanitary code enforcement. In order to accomplish this, BEAH needs to know identifying and health information about the tenant's asthma condition and about the tenant's home. BEAH requires participating providers to affirm the following:

"By registering below I affirm that prior to making a referral to BEAH, I will secure my patients'/clients permission to disclose information about their name, their asthma condition and their home address. I will inform my clients that the professionals working with BEAH will use the information only for purposes of enforcing the State Sanitary Code through inspection and, if necessary, housing court processes."

• I aggree and would like to register.
• I do not want to register at this time.