Forms – Child First Authorization to Disclose

Child First Authorization To Use and Disclose Health Information

Child First Authorization to Use and Disclose Health Information 2020-09-29

Connecticut Authorization for Child First Services and To Use and Disclose Health Information
Child Name*
First Last
Child Date of Birth*
MM slash DD slash YYYY
Are there any other children?*
- Yes
- No
Child Name (2)*
First Last
Child Date of Birth (2)*
MM slash DD slash YYYY
Child Name (3)
First Last
Child Date of Birth (3)
MM slash DD slash YYYY
Health Information Disclosure
Acknowledgement of Consent to Services*
- I authorize the Child and Family Agency of Southeastern Connecticut to provide Child First services to my child, to me and to other members of my family in conjunction with the care provided to my child. These services will include, but are not limited to: observations; screenings; assessments; home visits; psychotherapeutic treatment, as needed; visits to early care, education, or other sites; referrals to service providers; and conferencing and consultations with other professionals. I understand that my child’s and my family’s participation in the Child First program is voluntary. I also understand and agree that the Agency may videotape me, my child and my family for therapeutic or supervisory purposes. I further understand that services may be stopped at any time.
Acknowledgement of Disclosure of Treatment and Personal Information*
- To the extent my authorization is legally required, I authorize the Agency to disclose all treatment and other relevant information about me, my child and my family for purposes of treatment, payment, quality review and improvement and/or other health care operation activities, to the following parties: Child First Inc., entities that fund or reimburse for Child First services. This authorization includes permission to disclose HIV-AIDS related information, mental health treatment information, if applicable.
Acknowledgment of Right to Revoke Authorization*
- I understand that I may revoke this authorization in writing at any time, with a signed statement addressed to the program manager, except to the extent that action has already been taken in reliance on this authorization.
Notices
HIV/AIDS-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 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.
In the event that information released constituted privileged psychiatrist-patient, psychologist-patient, or social worker-patient communications: The confidentiality of this record is required under chapter 899 of the Connecticut General Statutes. This material shall not be transmitted to anyone without the written consent or other authorization as provided in the aforementioned statutes.
In the event that information released is protected by the federal confidentiality of Alcohol and Drug Abuse Patient Records regulations: This information has been disclosed to you from records protected by federal confidentiality rules (42 C.F.R. 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 C.F.R. 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.
By signing below, I acknowledge that I have read and understand this Authorization.
Parent/Guardian Signature*
Today's Date*
MM slash DD slash YYYY
Are there other adults receiving Child First services in conjunction with care provided to the child?*
- Yes
- No
Other adults receiving Child First services in conjunction with care provided to the child:*
- I voluntarily agree to participate in the Child First services. I understand and agree to the terms of this Authorization as they relate to my participation in the services and to the use and sharing of my health and personal information in connection with the services.
Signature of Adult (1)*
Signature Date (1)*
MM slash DD slash YYYY
Signature of Adult (2)
Signature Date (2)
MM slash DD slash YYYY
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Forms – Child First Authorization to Disclose

Child First Authorization To Use and Disclose Health Information

Connecticut Authorization for Child First Services and To Use and Disclose Health Information

Health Information Disclosure

Notices

Please click SUMBIT when done