Free AUTHORIZATION FOR RELEASE OF INFORMATION - Connecticut


File Size: 338.3 kB
Pages: 2
Date: December 15, 2008
File Format: PDF
State: Connecticut
Category: Court Forms - State
Author: RP
Word Count: 1,063 Words, 6,899 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://www.jud2.ct.gov/webforms/forms/cl046.pdf

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AUTHORIZATION FOR RELEASE OF INFORMATION
JD-CL-46 Rev. 12-08 C.G.S. 10-154a, 31-128f, 52-146b to 52-146o From (Full name of person giving permission to release information)

STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov
Information Needed By (Date)

I

Address

To:
II

Instructions 1. Person giving permission: In section II, specify hospital, school, physician, clinic, laboratory, pharmacy, insurer or other health care provider that has the information; complete section VII and sign before a witness. 2. Judicial Branch personnel: Complete sections I, III, IV, V and VI.
Date of Birth

III. Release Information Pertaining To:
Name (Full name of Subject of Record) (Check if authorization is for information concerning a minor child)

IV. Type Of Information To Be Released:
Instructions: The individual completing this authorization should be advised that this form may not be used to release both psychotherapy notes and other types of health information. If this form is being used to authorize the release of psychiatric health information, a separate form must be used to authorize release of any other health information. Authorizations for use or disclosure of sensitive health information (such as HIV/AIDS or substance abuse) should be initialed by the requestor. ("X" All that apply):

Entire Medical Record Only information related to (specific diagnosis, injury, operation, etc.) to Billing Records Psychotherapy Notes ONLY* (by checking this box I am waiving any psychotherapist-patient privilege) School Transcript Other:
* PSYCHOTHERAPY NOTES means notes recorded (in any medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of an individual's medical record.

I specifically authorize the release of the following sensitive information from my health record. (Initial all that apply) Substance Abuse (Alcohol/Drug) Confidential HIV/AIDS Related Information Mental Health (Other than psychotherapy notes) Sexually Transmitted Disease Genetic Testing

Only the period of events from

V. Purpose Of Authorization/Disclosure
This request for disclosure is being made at the request of the individual for purposes related to the case identified in this section which may include, but not be limited to, court ordered investigation, supervision and mediation/negotiation: Court

Judicial District

Geographical Area Number

Juvenile Matters

At (Town)

Docket Number

If Supervision, show type and duration

VI. Send Information Requested To:
To the Recipient of this information: Review "Notice to Recipient of Information" on back/page 2.
Court Support Services Division Office Mailing Address Attention (Name of C.S.S.D. Officer or Counselor) Telephone Number

VII. Statement of Authorization
I ask and give permission to the person or institution named above to release to the Judicial Branch office specified above copies of the information requested in Sections III and IV of this form and I give permission to the Judicial Branch office to release that information, whether obtained by this or an additional authorization required by the person or institution named in Section II, by making it available for inspection, including any sensitive information identified in Section IV, to the Court, to parties to the case, to attorneys in this case, and to any appointed Guardian Ad Litem. These recipients must not further disclose this information except that non-sensitive health information may be disclosed for legitimate trial and trial preparation purposes related to this case. I have read this form/had this form read to me and I understand the purpose of this release of information. I understand that signing this is voluntary. My treatment, payment, enrollment in a health plan, or eligibility for benefits will not be conditioned on my authorization for this disclosure. I understand that I may inspect or have copies made of the information to be used or disclosed (excluding psychotherapy notes). I understand that under applicable law, the information disclosed under this authorization may be subject to further disclosure by the recipient and thus, may no longer be protected by federal privacy regulations. I understand that I may revoke this authorization, in writing, at any time by sending such written notification to the person or institution named above, except to the extent that action has already been taken in reliance on it; or, except in the case of disclosure to those persons within the criminal justice system who have made my participation in a program or service provided by the person or institution named above a condition of (1) the disposition of any criminal proceedings against me, (2) my release from custody or (3) my probation. My permission, unless expressly revoked earlier, automatically expires as stated below.

Give Date, Event or Condition on which your permission for release expires, which can be no later than the final disposition of your case Signature of person giving permission (If minor, signature of parent or guardian, unless pursuant to 19a-592) Date Signed Signature of Witness

If signed by a legal representative, indicate relationship to subject of record and provide the appropriate documentation to verify your authority (Parents excluded from documentation requirement): Executor Power of Parent Guardian Conservator of Estate Attorney DISTRIBUTION: ORIGINAL - Party holding requested information COPY 1 - C.S.S.D. Office COPY 2 - Authorizing Individual

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Notice To Recipient Of Information Federal and state law prohibit making any further disclosure of alcohol and/or drug abuse information (42 CFR Part 2), educational records for a minor obtained under 34 CFR Part 99 (Family Educational Rights and Privacy Act (FERPA)), HIV-related information (Chapter 368x of the C.G.S.), psychiatric or other mental health information (Chapter 899 of the C.G.S.), without specific written authorization. If the disclosure contains information relating to HIV-related information, alcohol or drug abuse information, the following notice applies: This information has been disclosed to you from records protected by Federal confidentiality rules (42 CFR Part 2) or state law. The Federal rules or state law prohibit you from making any further disclosure of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by said law. A general authorization for the release of medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

JD-CL-46 Rev. 12-08 (back/page 2)

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