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Consent to Release Form


  2. I, the below named legal Parent / Guardian, on behalf of myself and/or my children and/or wards named in Section I, authorize the agencies listed in Section III, to release and share among themselves the selected confidential information listed in Section II:. My execution of this Consent to Release form releases these agencies and individuals from any and all liability arising from the release and disclosure of such information and records.
  3. Section I
    Child / Ward Information & Authorization of Confidential Information
  4. One Per Line: List the Child / Wards Full Name and Date of Birth. Any missing information will delay processing this form.

  5. Authorized Confidential Information*

    I authorize the following confidential information to be released and disclosed between the agencies listed below.
    Select each item you want to authorize the below listed agencies to share among themselves.

  6. If 'Other' was selected above, enter in details of other information that you are authorizing the below listed agencies to share.

  7. Exceptions of Authorization?*
    Is there is any information you want to be exempt from sharing among the below listed agencies?
  8. Consent Acknowledgement*

    The Consent to Release authorizes release of information and records that are protected under Federal and State regulations governing confidentiality, including but not limited to, 42 C.F.R. Part 2, 45 C.F.R. Part 160, the Health Insurance Portability and Accountability Act ("HIPAA") and the Family Educational Rights and Privacy Act ("FERPA") and cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that none of the agencies listed herein may condition my treatment on whether or not I sign this form.

  9. Section II
    Authorized Agencies & Consent to Release Information
  10. All of the following agencies/individuals may participate and are included in the authorization
  11. If 'Other' was selected above, enter in details of other information that you are authorizing the below listed agencies to share.

  12. Section III
    Consent & Electronic Signature
  13. Purpose of Consent to Release:

    This Consent to Release is intended for the purpose of allowing the release of information critical to allow certain agencies to coordinate and manage the provision of services to children and families who would benefit from integrated multi-agency services. This Consent to Release authorizes the sharing of information among the listed entities, many or all of which are authorized to view such information pursuant to applicable state or federal law.

  14. This Consent to Release automatically ends one year from the date I sign this form, or when the sharing of information is no longer needed to manage or provide services to me, my child(ren), or wards, or when I revoke my consent, whichever is sooner, except to the extent that the program or person authorized to make the disclosure has already acted in reliance on this consent.

    I understand I may revoke this authorization at any time by signing the revocation statement below and providing this document to the agencies listed in this Consent to Release. Agencies and providers who are listed in this Consent to Release and request information under this release may use a copy or facsimile (FAX) of this form in place of the original signed consent form. I agree that this information may be re-disclosed to all agencies listed if necessary to fulfill the purpose of the Consent to Release and understand the potential that such re-disclosure may mean the information or records are no longer protected by HIPAA.

  15. This Consent to Release has been explained to me. I have read it (or it was read to me) and understand its provisions. I have taken a reasonable amount of time to ask questions and consider whether to permit sharing of this information. I hereby willingly agree to share information as described above. I am aware I can elect to receive an electronic copy of this Consent to Release form by checking the box at the bottom of the form and providing an email address before submitting, or I can request a paper or electronic copy from Juvenile Services directly.*
  16. By electronically signing & dating the document below, I agree to follow the above requirements. I agree my electronic signature is a binding agreement.
  17. Section IV
    Modification and/or Revocation of this Consent to Release
  18. If you choose to modify or revoke a Consent to Release form that was previously submitted online, contact Juvenile Services at (970) 641-7908 to begin the process.
  19. Leave This Blank:

  20. This field is not part of the form submission.