Fill and Sign the And Mental Health Information

JV-226, Page 1 of 3 New January 1, 2013, Optional Form JV-226 Authorization to Release Health and Mental Health Information I am the This form authorizes the releas e of the child’s health and/or mental health records to the ch ild welfare agency to ensure that the child receives appropri ate and effective services. It also allows the agency to carry out its case management responsibilities; to monitor treatment, health-care operations, and billing and payment; and to inform the court of the child’s medical and/or mental health needs. This form complies with the Health Insurance Portabili ty and Accountability Act (HIPAA), Confidentiality of Medical Information Act (CMIA), and Lanterman-Pe tris-Short (LPS) Act. I give the following child welf are agencies and individuals pe rmission to release health information about me the child 1 2 3 I am the parent, legal guardian, or Indian custodian and I authorize release of the following medical information. Mental health information c ontained in the medical file may not be released. Parent Legal guardian Child, and I am eligible to consent Medical histories Diagnoses Immunizations Lab reports None I understand that I may refuse to sign this form. I unders tand that the child cannot be denied treatment just becau se I choose not to sign. (Check all that apply): Authorization to Release Health and Mental Health Information (Dependency) Fill in court name and street address: Superior Court of California, County of Child’s Name: Fill in child's name and date of birth: Date of Birth: None Indian custodian 1 2 3 6 7 8 9 1 2 4 5 6 7 8 The parent, legal guardian, or Indian custodian may only complete items , , , , , , and . The child may only complete it ems , , , , , , and . Case Number: a. b. c. d. a. b. c. d. e. f. X-ray reports g. h. Judicial Council of California Case Number: Child’s name: JV-226, Page 2 of 3 Authorization to Release Medical and Mental Health Information (Dependency) HIV information, including test results Mental health diagnoses Outpatient mental health treatment or counseling records Records regarding infectious, contagious, or co mmunicable disease if law or regulation requires the disease or condition to be reported to the local health officer None 5 Only the child, regardless of his or her age, may authorize release of the following information. Pregnancy records Reproductive health records None I am the child, and I au thorize the following info rmation to be disclosed (check all that apply): I discussed the contents of this form with my attorney before deciding whether or not to sign this form. I un derstand that I may refuse to sign this form. I understand that I cannot be denied treatment just because I choose not to sign. Sexual assault treatment records, if the child consented to this treatment Records regarding sexually transmitted diseases 7 I understand that the child welfare agen cy may share or be required to share my the child’s health and/or mental health information with certain persons or agencies for purposes of treatment, health- care operations, billing and paymen t, or as otherwise required by law, without having to ask for my permission. I understand that if this health and mental health information is disclosed to someone who is not legally required to keep it confidential, it may be redisclosed and may no longer be protected. 6 I give permission to release my the child’s health information specified by the checked boxes in items 3, 4, a nd 5 and to discuss them with (name of child welfare agency): . 4 If the child is between 12 and 18 years old, the child may authorize release of the following information. I discussed the contents of this form with my attorney before deciding whether or not to sign this form. I unde rstand that I may refuse to sign this form. I understand that I cannot be denied treatment just because I choose not to sign. New January 1, 2013I am the child and I auth orize the following inform ation to be disclosed (check all that apply): a. b. c. d. e. f. a. b. c. d. Case Number: Child’s name: JV-226, Page 3 of 3 Authorization to Release Medical and Mental Health Information (Dependency) 10 This authorization automatically ends one year from date of signature. (SIGNATURE) (TYPE OR PRINT NAME OF PARENT/LEGAL GUARDIAN) Date:  (SIGNATURE) (TYPE OR PRINT NAME OF CHILD )  The health-care provider may refuse to rele ase the records if he or she determines that access to the child’s records would ha ve a detrimental effect on the provider’s professional relationsh ip with the child or the child’s physical sa fety or psychological well-being. This form is not intended to abrogate the righ ts of court-appointed counsel for the child to access records pursuant to Welfare and Institu tions Code section 317(f) or court order. 11 New January 1, 2013 9 I understand that I may revoke this authorization by writing to (name and address of person to whom revocation should be directed): Once this person receives my written request, this authoriz ation will be revoked, but only to the extent that the author ization has not already been re lied upon to release health information. I request a copy of this form. 8 I do not want a co py of this form. I request a copy of the reco rds that will be released. I am the child and understand th at I do not have to give this form to my parent or legal guardian. a. b. c. d. IMPORTANT: PLEASE READ