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Child and Family Agency

Child and Family Agency

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Forms – Authorization for Release of Information


Authorization for Release of Information (rev 20211005)

rev. 20211005
  • Authorization For the Release of Information

  • (Client receiving services)
  • (Client receiving services date of birth)
    MM slash DD slash YYYY
  • (Individual whose information will be shared with the named information recipient identified below)
  • MM slash DD slash YYYY
  • First and Last NameDate of BirthRelation to Person Granting Permission 
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • By signing below, I understand and acknowledge the following:

    • I understand this authorization will expire one year from date signed, unless cancelled.
    • 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 Child and Family Agency 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.

  • MM slash DD slash YYYY
  • Note: Confidentiality of psychiatric, drug and/or alcohol abuse, and HIV records is required and no information from these specific records shall be transmitted to anyone else without written consent or authorization under Connecticut General Statutes, Chapters 899c and 368x and Federal Regulations 42 CFR 2. These laws prohibit the recipient of the record from making any further disclosure without specific written consent of the person to whom the record pertains. A general authorization of the release of this information is NOT sufficient for this purpose.
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