Vista Del Camino 7700 E Roosevelt St.

Phone: 480-312-2323 and Fax: 480-312-7715

HUMAN SERVICES
AUTHORIZATION TO OBTAIN/RELEASE
CLIENT RECORDS AND/OR INFORMATION
SOCIAL SERVICE ELIGIBILITY
In order to better assist you, or your minor child or children, there are times when we may need to
obtain or release personal information. This information will only be released or obtained with your
approval, as you indicate below. Please initial boxes below to indicate that you authorize releasing
and/or obtaining personal information relating to the following: PLEASE INITIAL NEXT TO THE X's.
Release Obtain
Bank records
Billing statements x R x R
Employment (current and past) x R x R
Federal, State, and County agencies x R x R
Housing information x R x R
Legal
Medical
Psychological
School information
Salvation Army
St. Vincent de Paul
Other

I HEREBY AUTHORIZE City of Scottsdale Human Services Staff to release and/or obtain the
information indicated immediately above to/from the following individuals or organizations, as
applicable. Name/Organization: Maricopa County Human Services Department
Utility Companies: APS SRP SW Gas Other:
______________________________________________________________________________
Landlord/mortgage company: Wayne/kelly Nelson Phone number: 8052254868

I understand that the contents of my client record, or that of my minor child or children, as applicable,
including the information indicated above, may be discussed between Human Services staff members
for the purposes of supervision and case coordination, and shared with crisis intervention staff
members, as deemed necessary and appropriate. I also understand that I may withdraw this consent at
any time, except as to actions that have been already taken, by making a written request to a
representative of Human Services.

Print Name: x Karla R Chavez Signature: x Date: x 03/24/2024

Print Guardian/Parent Name (as applicable):

Guardian/Parent Signature (as applicable): Date:

This document may not exceed 1 year from date of client authorization
Created 8/17/17
 Vista Del Camino 7700 E Roosevelt St. Phone: 480-312-2323 and Fax: 480-312-7715

HUMAN SERVICES
CONFIDENTIALITY POLICY

The Scottsdale Human Services Department is not a licensed clinical behavioral health center and does not
provide counseling services.

Scottsdale Human Services respects the importance of confidentiality in our relationships with youth, adults, and
families utilizing our services. The Human Services Department stores records safely and confidentially.
Electronic records are stored in the Human Services electronic records system. Paper records are stored in a
secure locked facility. All records are destroyed in accordance with City of Scottsdale Records Destruction Policy.
Individual client information is released outside of Human Services under the following circumstances:

 Informed consent – A client, or the client’s parent or legal guardian, as applicable, gives written
authorization to release information.
 To appropriate authorities when the behavior of the client is considered a “danger to self.”
 To appropriate authorities, when the behavior of the client is considered a “danger to others.”
 In response to a court subpoena, court order or search warrant.
 To comply with mandatory reporting laws, A.R.S. 13-3620 & A.R.S. 13-3623, relating to possible abuse
of children, dependent adults or the elderly.

By signing below, I understand that the contents of my client record, or that of my minor child or children,
as applicable, may be discussed between Human Services staff members for the purposes of supervision
and case coordination. I further understand that client record information may be subject to disclosure to
persons other than Human Services staff, as indicated above.

Client
Print Name Karla R Chavez
Client Date
Signature 03/24/2024
Parent/Guardian
Print Name
Parent/Guardian Date
Signature
HS Witness
Print Name
HS Witness Date
Signature

This document may not exceed 1 year from date of client authorization
Created 8/17/17
 CITY OF SCOTTSDALE, ARIZONA
COMMUNITY ACTION PROGRAM
GRIEVANCE PROCEDURE

The City of Scottsdale has developed the following internal grievance procedure to assure
compliance with funding sources, and to resolve concerns and complaints at an early
stage. This procedure may be used by anyone who wishes to file a complaint in the
provision of services, activities, programs or benefits received at Vista del Camino
through the Community Action Program. Use of this procedure does not affect other
rights and remedies that may be available under federal and state statutes prohibiting
discrimination on the basis of disability.

1. Any complaint or report should be made in writing and contain information about
the grievance, such as name, address, telephone number of complainant and
location, date, and description of the problem.
2. The complaint should be submitted by the complainant and/or designee as soon
as possible. Complaints should be submitted no later than 60 business days after
the alleged violation. The complaint should be directed to the Human Services
Manager at the following address:

Human Services Manager

Vista del Camino
7700 E. Roosevelt,
Scottsdale, AZ 85257

3. Should any complaints reference discrimination on the basis of disability, they

shall be promptly and thoroughly investigated by the ADA Coordinator or designee
and you will be provided with appropriate contact information and procedures to
file a formal ADA grievance.
4. Within 3 business days of receipt of the complaint or report, the Human Services
Manager will discuss and/or meet with the complainant to discuss the complaint
and possible resolutions.
5. Within 10 business days after the discussion/meeting, the Human Services
Manager will document and date this discussion and provide the complainant with
a copy of the written documentation of the submittal/decision.
6. If the response does not satisfactorily resolve the issue, the complainant or the
complainant's representative may appeal the Vista del Camino Human Services
Manager’s decision to the City of Scottsdale Community Services General
Manager, or designee within 10 business days after receiving the response.
Written information may be communicated to: City of Scottsdale Comm unity
Services Administration, Attention: Community Services Executive Director, One
Civic Center, 3rd Floor, Scottsdale, AZ 85251.
7. Within 3 business days after receipt of the appeal, the Community Services
Executive Director, or designee will contact the complainant to discuss the
complaint and possible resolutions.
8. Within 10 business days after the meeting, the Community Services Executive
Director, or designee will respond in writing with a final determination regarding the
complaint. A copy of the final determination will be provided to the complainant.
Revised 02/21/18 FINAL
 9. The Human Services Manager shall review all client grievances for the purpose
of continuous quality improvement. A record of client grievances shall be kept as
part of the quality improvement documentation. City of Scottsdale administrative
management may review as appropriate.
10. Vista del Camino shall maintain the files and records relating to complaints for a
period of three years. Such documents shall be maintained as confidential
records.

If the concern/grievance/appeal is in regards to services funded by the

Maricopa County Human Services Department, the following step is available
to you:

If you feel the City of Scottsdale has not satisfactorily resolved your complaint, you
may present your concern, grievance, or appeal, in writing to the Program
Administrator at the Maricopa County Human Services Department / Community
Services Division (MCHSD/CSD), 234 N. Central, Suite# 3000, Phoenix, AZ 85004.
This must be received within ten (10) business days of the date of the Human
Services Manager’s or Community Services Executive Director’s written response.
The MCHSD/CSD Program Administrator will review the grievance for resolution. A
written response will be provided to you within ten (10) days of receiving the written
request.

If the concern/grievance/appeal is in regards to services funded by the State of

Arizona Department of Economic Security through MCHSD/CSD, the following
step is available to you:

If you continue to feel that the problem has not been resolved to your satisfaction,
you may present your written grievance to the Arizona Department of Economic
Security (DES) Division of Aging and Adult Services (DAAS) . Assistant Director,
P.O. Box 6123, Site Code 950A, Phoenix, AZ 85005. The phone number for DES:
602-542-6600, Fax: 602-364-1756. Your written request should be submitted within
ten (10) days after receiving a response from MCHSD/CSD. A final decision will be
made within 30 days from the date the appeal is received by DES/CSA and you will
be notified in writing.

I have read and received a copy of the Grievance Policy outlined above.

Client Signature____________________________________
Date:______________
03/24/2024

Revised 02/21/18 FINAL