IICAPS Authorization for Release of PHI (rev 20200506) Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS) Authorization For Release of Protected Health Information Individual covered - name* First Last Individual covered - date of birth* MM slash DD slash YYYY Case name(if different from individual covered) First Last Case name - date of birth MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Other person (1) covered by this release Other person (1) date of birth MM slash DD slash YYYY Other person (2) covered by this release Other person (2) date of birth MM slash DD slash YYYY Other person (3) covered by this release Other person (3) date of birth MM slash DD slash YYYY 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. 1. Please use or disclose the following health information, if such information exists:*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. The entire medical record (all information maintained by Child & Family Agency for the time period indicated below or maintained by the information source named in # 2). To include HIV/AIDS information To include drug and alcohol information The following limited health information (to be listed below) Limited health information:*2. Please specify the information source/destination and/or individuals that may obtain or release the information according to the limitations described above* Select All Yale Intensive In-Home Child and Adolescent Psychiatric Service (IICAPS) Address: Yale Child Study Center, 47 College St., Suite 218, New Haven, CT 06510 CT Dept. of Children and Families and its agents and legal representatives Address: Central Office and applicable Regional Office 3. 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 4. Please specify the purpose(s) for which the information is being requested:*Check all that apply below Yale IICAPS staff attendance at/participation in service reviews / IICAPS rounds DCF quality assurance staff attendance at face-to-face service reviews / IICAPS rounds 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 Submission to Yale IICAPS of all standard IICAPS clinical forms (e.g. referral information; assessments; treatment plans; discharge summaries, etc., including identifying information); and Submission to the program’s funding source, DCF, required identifying program reporting information 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. Signature of Individual covered or Parent/Legal Guardian* Date of signature* MM slash DD slash YYYY If signed by other than client, describe the legal authority of the representative to act on behalf of the individual: Parent Other legal guardian DCF worker 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.