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Child and Family Agency

Child and Family Agency

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Forms – IICAPS Auth for Release of PHI


IICAPS Authorization for Release of PHI (rev 20200506)

  • Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS) Authorization For Release of Protected Health Information

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  • (if different from individual covered)
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  • I authorize the use or disclosure of my protected health information by Child & Family Agency as specified below. I understand that I have the right to revoke this authorization at any time by providing a signed, written notice of such revocation to Child & Family Agency. I understand that a description of my right to revoke my authorization is set forth in Child & Family Agency’s Notice of Privacy Practices.

  • Please be advised that once we disclose/obtain this information per your instructions the information is subject to re-disclosure and may be releasable to a parent/guardian or other service provider upon their request and may no longer be protected by HIPAA.
  • MM slash DD slash YYYY
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  • Check all that apply below
  • If no date specified, this release will expire one year from signature date below. (Maximum one year, or 90 days after discharge, whichever comes first)

    By signing below, I understand and acknowledge the following:

    • I have read and understand this Authorization;
    • If I have any questions about disclosure of my protected health information pursuant to this authorization, I may contact the agency Privacy Officer, Karen Ethier-Waring, LMFT at 860-443-2896.

  • MM slash DD slash YYYY
  • STATEMENT REGARDING CONFIDENTIAL INFORMATION

    Psychiatric Records and Communications

    In the event that information released constitutes privileged psychiatrist-patient communication: The confidentiality of this record is required under Chapter 889 of the Connecticut General Statutes. This material shall not be transmitted to anyone without written authorization as provided in the aforementioned statutes.

    Drug and Alcohol Abuse Records

    In the event that information released is protected by the HHS confidentiality of Alcohol and Drug Abuse Patient Records regulations: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR 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 CFR 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.

    HIV 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 the 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.

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