Authorization for Release of Information (rev 20211005) rev. 20211005 Authorization For the Release of Information Case Name(Client receiving services) First Last Case Name Date of Birth(Client receiving services date of birth) MM slash DD slash YYYY Identified Client Name*(Individual whose information will be shared with the named information recipient identified below) First Last Identified Client Date of Birth* MM slash DD slash YYYY Identified Client PhoneIdentified Client Email Relation to person granting permission* Self Dependent Are there additional subjects of PHI release?* Yes No Additional Subjects of PHI Release*First and Last NameDate of BirthRelation to Person Granting Permission Type of Release* Authorization for Release of Protected Health Information Authorization for Release of Protected Health Information to DCF Authorization for Release of PHI to DCF-ACR/Permanency Team Is this release for a school district?* Yes No Name and/or Organization of Information Recipient* Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Please specify the recipient information and/or individuals that may obtain or release the information according to the limitations described below.** Recipient information School Nurse(s) (with the understanding that some school nurses are employed by other entities, such as the VNA of Southeastern CT, etc.) Authorization for Release of Protected Health Information for participation in PPT-504 multi-disciplinary meetings (Optional) Youth Officer(s) assigned to this student’s school Name of Police Department* Please specify the information recipient, in addition to Case Involved Staff, that may obtain or release the information according to the limitations described* Please specify the information recipient, in addition to Case Involved Staff, that may obtain or release the information according to the limitations described* School District Name* School District Location* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State CT Department of Children & Families* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Types of Record(s) to be released (check all that apply):* Psychiatric Medical Education Psychotherapy Summary Documents Other Describe other record(s) to be released*I specifically authorize release of the following sensitive information from my/my child's record Substance abuse (alcohol/drug) Confidential HIV/AIDS related information Purpose of authorization/disclosure* Ongoing service planning and coordination Purpose of authorization/disclosure* Ongoing service planning and coordination Provision of information to DCF staff (e.g. caseworkers; supervisors) and DCF’s agents and legal representatives regarding client participation in Child and Family Agency’s services and progress on service goals. Nature and extent of information to be disclosed* Entire medical record Limited health information Describe limited health information (e.g. attendance and dates of service)Please specify the time period the disclosed information should relate to:* No limitations on time frame Only time frame specified below Time frame starting on:* MM slash DD slash YYYY Time frame ending on:* 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. Electronic signature of person authorizing disclosure or authorized representative* Today's Date* MM slash DD slash YYYY Check below if this form has been signed by a person other than the subject of the record* Parent/Guardian Attorney Guardian ad litem Other Explain other relationship to subject of the record* 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.
