Healthcare DCFS Release Form

HEALTHCARE DCFS RELEASE FORM

Patient Information

Patient Name:

Date of Birth:   Gender:

Recipient (DCFS) Information

Authorization and Purpose

I hereby authorize the health care provider identified below to disclose the protected health information specified in this form to the Department of Children and Family Services (DCFS) identified above. Purpose of disclosure (check all that apply):

Case management and service planning

Investigation of child welfare concerns

Court proceedings, placement, or dependency hearings

Other:

Records to Be Released

Check the types of information to be released:

Entire medical record for the period specified

Treatment summaries and discharge summaries

Mental health and behavioral health records

Substance use treatment records (special protections apply)

Psychotherapy notes (initial authorization required)

Laboratory and test results, including infectious disease testing

Immunizations and vaccination records

Medication lists and medication administration records

School and educational health records

Billing and insurance information

Time Period

Dates of records to be released: From to

Authorization Term and Revocation

This authorization will expire on: or upon occurrence of the following event:

I understand that I may revoke this authorization at any time by delivering a written revocation to the releasing health care provider, except where actions have already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of the revocation.

Redisclosure and Limitations

I acknowledge that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal privacy rules. Certain records (for example, psychotherapy notes and substance use disorder treatment records) are afforded special protections and require specific authorization to be released. By signing below I specifically authorize release of the categories I have indicated above.

Consequences of Refusal and Other Rights

I understand that treatment, payment, enrollment or eligibility for benefits will not be conditioned on signing this authorization unless the information is necessary to determine eligibility for a program or to provide care related to the purpose stated above. I understand I have the right to receive a copy of this authorization after I sign it.

Provider Releasing Information

Optional Medical Summary (to assist casework)

Special Authorizations

I specifically authorize release of substance use disorder treatment records protected by federal law.

I specifically authorize release of HIV/AIDS related testing and treatment records.

I specifically authorize release of psychotherapy notes (if checked, initial to indicate consent):

Acknowledgment and Certification

By signing below I certify that I am the patient or the patient's legal representative and that I have the authority to execute this authorization. I understand the contents, have had an opportunity to ask questions, and request disclosure as indicated. I understand that once disclosed, information may be subject to redisclosure by the recipient and may no longer be protected by federal privacy law.

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