Get Involved ›
Volunteer
Careers
Walk in counseling
Pay Bill
Forms
Contact Us
MENU
About Us
Our Mission
Our Story
Leadership
Partners
Publications
Get Involved
Contact Us
What We Do
In-Home Counseling
Outpatient Clinic
School-Based Health Centers
Early Care and Education
Education & Resources
Privacy Practices
Forms
News & Events
Press Releases
Agency News
Auxiliary News
Event Calendar
Photo Gallery
Get Involved
Calendar
Privacy Practices
Pay Bill
Forms
Contact Us
Donate
Give By Check
Give Online
Legacy Giving
Authorization for Release of PHI
Authorization For the Release of Information
Case Name
(Client receiving services)
First
Last
Case Name Date of Birth
(Client receiving services date of birth)
Date Format: 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
*
Date Format: MM slash DD slash YYYY
Identified Client Phone
Identified 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 Name
Date of Birth
Relation 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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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.)
(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
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
CT Department of Children & Families
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed 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:
*
Date Format: MM slash DD slash YYYY
Time frame ending on:
*
Date Format: 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
*
Date Format: 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.
Donate Now