Authorization
for Release and Exchange of Information
The Linn-Benton-Lincoln Education Service District (n.d.) in Albany, Oregon, developed the following consent form for the Youth Services Teams in Linn County, Oregon:
I, ______(Parent/Guardian Signature)________, authorize the release of information between and among the identified Regional Youth Services Team members, which will be planning services for
______________________________________________________________.
Client(s) Name(s) (Please include all family members)
The purpose of the Authorization Form is to enable agencies identified as members of the Regional Youth Services Team to better serve your child through coordinated service planning and delivery. Representatives of these agencies will meet and share information regarding your child at scheduled planning and review meetings. In addition, this release will permit follow-up case coordination between the listed agencies.
The Regional Youth Services Team for your child shall include the following agencies:
To help the team determine the best resources available to your child, please check the appropriate box below:
___ Medical Card
___ Private Insurance
___ No Medical Card or Insurance
The information to be disclosed/exchanged is: presence in the program; and school, legal, and treatment records which include assessment, family history, and diagnosis and treatment recommendations from the Linn County Mental Health and Alcohol and Drug Treatment programs.
This release authorizes a free exchange of information between members in order to give the most complete and thorough services available. It does not authorize release to any other person or agency except those agencies listed above. Unless revoked in writing, this release and exchange shall remain in force for a period of 12 months from the date of authorization.
To the party receiving this information: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulation (42 CFR Part 2) prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is not sufficient for this purpose.
Authorized Signature _______________________
Relationship to Child _______________________
Juvenile's Signature (14 and over)_______________________
Witness ___________________________________
Date _________________________________"
