Authorization For the Release of Information

Case Name

(Client receiving services)

First Last

Case Name Date of Birth

(Client receiving services date of birth)

Identified Client Name*

(Individual whose information will be shared with the named information recipient identified below)

First Last

Identified Client Date of Birth*

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 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*

School District Name*

School District Location*

City State

CT Department of Children & Families*

Street Address Address Line 2 City 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:*

Time frame ending on:*

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*

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.

Authorization for Release of PHI

Authorization For the Release of Information