Authorization for Release of Protected Health Information

Individual covered name*

First Last

Individual covered - Date of birth*

Case name

(if different from individual covered)

First Last

Case Name - date of birth

Address

Street Address Address Line 2 City State ZIP Code

Other person (1) covered by this release

Other person (1) date of birth

Other person (2) covered by this release

Other person (2) date of birth

Other person (3) covered by this release

Other person (3) date of birth

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 recipient, in addition to Case Involved Staff, that may obtain or release the information according to the limitations described*

Information recipient address

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*

Time frame ending on*

4. Please specify the purpose(s) for which the information is being requested:*

Ongoing service planning and coordination, and
The following purpose specified below

Specified purpose for information disclosure

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*

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.

Authorization for Release of PHI

Authorization for Release of PHI (rev 20200407)

Authorization for Release of Protected Health Information