"Authorization to Release Confidential Records and Information

PARTIES NAMED IN RELEASE

[Instructions: This section must name the individuals whose records will be released, the relationship of the signator to that individual, and the agencies that send/receive the information.]

I, ___(name of parent/guardian)_____ and/or

____(minor/authorized representative)__

hereby authorize ___(agency, person, organization)____(street, city, state)____

to release to ___(agency, person, organization) (street, city, state)_____

confidential records regarding myself or the individual named below.

Name________________________ Birth Date _____________

INFORMATION RELEASED - PURPOSE/TYPE

[Instructions: Statements must clearly specify the information to be released and the purpose of the release.]

 This disclosure of information is required for the following purpose(s): Please initial the appropriate line(s).

____ Assessment
____ Service Plan
____ Other (Specify)

The disclosure shall be limited to requesting/releasing the following types of information:

[Instructions: This section must specify what will be released. It may not be a general release of agency files.]

____ Summary of Record
____ Social History
____ Treatment Plan
____ Financial Information
____ Psychiatric Evaluation
____ Medical Assessments, Lab Tests, etc.
____ History of Drug/Alcohol Abuse
____ Other Evaluations/ Assessments (Specify)_______________________
____ Results of Psychological/Vocational Testing
____ Other (Specify) ____________________________________________

CONDITIONS OF THE RELEASE

[Instructions: This section must cover all basic release requirements of all programs included in the integrated service program design.]

Effective Dates:

This consent becomes effective __________, 19___. This consent may be revoked by the undersigned at any time except to the extent that action has already been taken. If not revoked, it shall automatically terminate at the end of one year from the effective date or an earlier date of ___________.

Rights of Signators:

I understand: (1) I may receive a copy of this signed authorization; (2) I may view my case files, except when prohibited by law; (3) this release may result in disclosure of the fact that mental health, drug or alcohol service have been/ are being provided; (4) federal rules do restrict any use of the disclosed drug or alcohol information to criminally investigate or prosecute me or the individual named on this release.

Signature ______(Parent/Guardian/Authorized minor)_______

Date____________

DOCUMENTATION OF RELEASE

[Instructions: This is an optional section on this form. It is not an optional activity. The right to review is restricted by law to certain portions of the file and certain individuals. In some instances, the right is further restricted by requiring approval by the treating professional.]

REQUEST TO VIEW RECORDS AT THE CENTER

Signature______(Parent/Guardian/Authorized Representative or Minor)____

Date____________

Signature of Authorized Staff_______________________ Date__________

RECORD OF INFORMATION RELEASED

The following records and/or information was released to _________________.

____ Summary of Record
____ Social History
____ Treatment Plan
____ Financial Information
____ Psychiatric Evaluation
____ Medical Assessments, Lab Tests, etc.
____ History of Drug/Alcohol Abuse
____ Other Evaluations/ Assessments (Specify)_______________________
____ Results of Psychological/Vocational Testing
____ Other (Specify) ____________________________________________

Released by____(Signature)________ Title____________________

Date released____________________

AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION

Case name________________________

Case record no.____________________

Citations:

Health and Safety Code 1795
W&I Code 10850 and 5328
18951, 18986.40
Ed Code 49073
Civil Code 34, 56, and 1789
42 CFR Part 2"