Authorization For Release Of Information

Please fill out the information below or follow this link to download and print on your own: Click here to view the Authorization for Release of Information form
By filling out this form, you are agreeing to share information from another behavioral health or medical provider, school, individual or organization with Child and Family Agency of Southeastern CT, Inc. (CFA). This release grants permission for you to receive information to and from an individual or organization listed below.
Personal Information of CFA Client
Legal Name of Person Receiving Services*
First Last
Preferred Name (if any):
Date of Birth*
MM slash DD slash YYYY
Individual or Organization Information
Are you sharing information to an individual or a private or public organization?*
- Individual
- Private or Public Organization (i.e. school, Department of Children & Families, hospital)
Individual that you are sharing information with
Name*
First Last
Relationship with person receiving services:
Address*
Street Address (PO Box, Apartment #, etc.) City State ZIP Code
Phone Number:
Email Address:
Additional Information (if needed):
Private or Public Organization
Name of Organization:*
Address*
Street Address Address Line 2 City State ZIP Code
Fax (Optional):
Phone Number:
Contact Person Information (physician, social worker, attorney):
Additional Information (if any)
PHI Details
Please select what information you would like to be released by marking the box next to the item (select all that apply)*
- Psychiatric
- Medical
- Education
- Psychotherapy Summary Documents
- Other
Define:
I specifically authorize release of the following sensitive information about my records or my dependent’s records (select all that apply)
- Substance abuse (alcohol/drug)
- Confidential HIV/AIDS-related information
Acknowledgements
By signing below, I understand and acknowledge the following:
- I understand this authorization will expire one year from the date signed, unless cancelled.
- This release does not authorize information received from third-party members to be shared.
- I understand that refusal to sign this authorization form will not affect my right to obtain present and future services, except where disclosure of the records requested is necessary for services. I also understand that I may revoke this authorization by notifying CFA of the named recipient in writing. A revocation of this authorization will not apply to any records disclosed before the authorization is revoked. Pursuant to C.G.S. 17a-28(k) the information disclosed pursuant to this authorization is not subject to re-disclosure by the recipient without a separate authorization for that purpose except as provided by said statute.
Printed Name of person authorizing disclosure or authorized representative*
First Last
Signature of person authorizing disclosure or authorized representative*
Today's Date*
MM slash DD slash YYYY
What is your relationship to the client receiving services?*
- Parent
- Legal Guardian (other than the parent)
- Self
Define:*

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Personal Information of CFA Client

Individual or Organization Information

Individual that you are sharing information with

Private or Public Organization

PHI Details

Acknowledgements