AUTHORIZING RELEASE OF CONFIDENTIAL INFORMATION
One Per Line: List the Child / Wards Full Name and Date of Birth. Any missing information will delay processing this form.
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.
If 'Other' was selected above, enter in details of other information that you are authorizing the below listed agencies to share.
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.
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.
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.
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