Consent
to Participate and Authorization to Share Information
The Family Service Center of Bay Point/West Pittsburg (n.d.) in Bay Point, California, uses the following release form for clients:
"Bay Point/West Pittsburg Family Service Center
Consent to Participate and Authorization to Share Information
The Family Service Center is designed to improve services for the families of Bay Point/West Pittsburg:
In order for the Family Service Center to serve you and your family, Center staff must be able to talk with each other on your behalf and to review the records of each agency in the program. Family Service Center staff consists of representatives of the Contra Costa County Social Service Department, Health Services Department, Probation Department, Community Services Administration, and the Mt. Diablo Unified School District.
According to state and federal law, we need your permission to share information and records about you and your family. Information and records will not be given to anyone except staff of the Family Service Center and their supervisors. Supervisors will review information in your records to make sure that the programs are in compliance with county, state, and federal rules.
If information or records show that drug or alcohol treatment services are/have been provided to you, they cannot and will not be used to criminally investigate or prosecute you. Family Service Center staff are required to keep all information and records confidential.
Family Service Center staff are legally required to report any suspicion of child abuse to Protective Services.
If you and your family would like to be part of the Family Service Center, please initial each of the statements below to show that you have read, understand, and agree with each statement:
____ I wish to receive services for myself and my minor child(ren) at the Family Service Center.
____ I allow staff of the Family Service Center to share information and records about me and my family with other staff of the Center and their supervisors to plan, to check, and to see that I am receiving services and treatment that best meet my family's needs. The staff may share with each other the following types of records provided by me that will enable them to better provide services to me, including but not limited to:
Information in my Medi-Cal records, Aid to Families with Dependent Children (AFDC) records, General Assistance records, Greater Avenues to Independence (GAIN) records, Food Stamps records, Child Care records, Children's Protective Services records, Child Welfare Services Records, Juvenile Court records, Public Health records, Family Assessment Record (which contains information about my family's goals, strengths, needs, plan of action, and services to be received), school and job training records, financial information, and social history. In addition, the staff may share information about my work with the following other agencies:
_____________________, ______________________, and _____________________.
We will not share information about your medical records, psychiatric/psychological evaluations and drug/alcohol abuse records without first asking you for your written permission.
Your agreement to participate in the Family Service Center and permit sharing information begins ____________, 19___, and ends ____________, 19___ (1 year). You may cancel your consent at any time during the year. No information will be shared with anyone after the date you quit the Center.
Your consent applies to you and your minor child(ren), including the child(ren) for whom you are the legal guardian. Please print the names and birth dates of your minor child(ren).
Child's name____________________ Birth date___/___/___
Child's name____________________ Birth date___/___/___
Child's name____________________ Birth date___/___/___
Child's name____________________ Birth date___/___/___
Child's name____________________ Birth date___/___/___
If you have any questions, please ask. Your participation is important. We want to do a good job working with you to achieve your goals.
Signature_____________________________ Date_______________
Name (please print)______________________ Birth date___/___/___
Social Security #___________________________
Address__________________________________________
City _________________________ Zip Code_______________
Witness
Signature____________________________ Date____________
Name (please print)____________________ Title_______________
This form is designed to comply with Health & Safety Code 1795; Welfare and Institutions Code 10850 and 5328; Education Code 49073; Civil Code 56 and 1796; and 42 CFR Part 2. All records governed by 42 CFR Part 2 shall include the statement 'This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations, 42 CFR, Part 2, prohibit 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.' "
