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Child and Family Agency

Child and Family Agency

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Forms – Child First Authorization to Disclose


Child First Authorization To Use and Disclose Health Information

Child First Authorization to Use and Disclose Health Information 2020-09-29

  • Connecticut Authorization for Child First Services and To Use and Disclose Health Information

  • MM slash DD slash YYYY
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  • Health Information Disclosure

  • Notices

      HIV/AIDS-related information
    In the event that information released constitutes confidential HIV-related information protected under Connecticut law: This information has been disclosed to you from records whose confidentiality is protected by state law. State law prohibits you from making any further disclosure of it without specific written consent of the person to whom it pertains, or as otherwise permitted by said law. A general authorization for the release of medical or other information is NOT sufficient for this purpose.
      Social Work Records and Communications
    In the event that information released constituted privileged psychiatrist-patient, psychologist-patient, or social worker-patient communications: The confidentiality of this record is required under chapter 899 of the Connecticut General Statutes. This material shall not be transmitted to anyone without the written consent or other authorization as provided in the aforementioned statutes.
      Drug and Alcohol Abuse Records
    In the event that information released is protected by the federal confidentiality of Alcohol and Drug Abuse Patient Records regulations: This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. Part 2). The federal rules prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 C.F.R. Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.
  • By signing below, I acknowledge that I have read and understand this Authorization.
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Please click SUMBIT when done

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