AUTHORIZATION FOR RELEASE OF INFORMATION

Please fill out the information below or follow this link to download and print on your own: Click here to view the Authorization for Release of Information form

By filling out this form, you are agreeing to share information from another behavioral health or medical provider, school, individual or organization with Child and Family Agency of Southeastern CT, Inc. (CFA). This release grants permission for you to receive information to and from an individual or organization listed below.

Whose Information is Being Released?

Legal Name of Person Receiving Services*

First Last

Preferred Name (if any):

Date of Birth*

What is your relationship to the client receiving services at CFA?*

Self

Parent

Legal Guardian (other than the parent)

Define:*

If you are someone other than the client, please identify the client receiving services from CFA.

Name*

First Last

Date of Birth*

Individual or Organization Information

Information released for the purpose of*

Care Coordination

Other

Other*

Are you sharing information to an individual or a private or public organization?*

Individual

Private or Public Organization (i.e. school district, Department of Children & Families, hospital)

Individual that you are sharing information with to and from:

Name*

First Last

Relationship with person receiving services:

Address

Street Address

Address

(PO Box, Apartment #, etc.)

Address*

City

Address*

State

Address

Zip Code

Phone Number:

Email Address:

Additional Information (if needed):

Private or Public Organization to and from:

Name of Organization:*

Address

Street Address

Address

(PO Box, Apartment #, etc.)

Address*

City

Untitled*

State

Address

Zip Code

Fax (Optional):

Phone Number:

Contact Person Information (physician, social worker, attorney):

Additional Information (if any)

PHI Details

Please select what information you would like to be released by marking the box next to the item (select all that apply)*

Complete Health Record

Last History & Physical Exam

Lab Results

Immunization Record

Medication List

Mental Health Evaluations

Progress Notes

Summary of Treatment

Other

Define:

Sensitive Health Information

Check each box below to disclose the following:

Substance abuse (alcohol/drug)

Reproductive Health

Confidential HIV/AIDS-related information

Clients between 13-17 years of age must consent for the release of sensitive health information. If you are a parent/guardian and any of the three top boxes are checked, a CFA representative will be reaching out to your adolescent for their consent and giving them a copy of this form.

Acknowledgements

By signing below, I understand and acknowledge the following:

I understand this authorization will expire one year from the date signed. I understand that after I sign this form, I may cancel this authorization at any time by contacting CFA in writing.
The parent or legal guardian must sign this authorization if the patient is a minor (under age 18) unless the records relate to treatment(s) for which the minor may provide consent under CT state law. If HIV, Drug/Alcohol information is included, the minor must sign as described above.
Medical records containing protected information under applicable federal or state laws must also be authorized by a minor when age 13 or older (e.g. HIV, substance abuse including alcohol and drug abuse, reproductive health, and/or sexually transmitted disease).
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 CFA 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.

Printed Name of person authorizing disclosure or authorized representative*

First Last

Signature of person authorizing disclosure or authorized representative*

Today's Date*