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.
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:
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.