To Our Clients: We can help you better if we are able to work with other agencies that know you and your family.
By signing this form, you are giving permission for these organizations to share information about your situation.
Name
D.O.B.
ID #
(Use SS# for Employment and Vocational Rehabilitation)
Children
I authorize the following individuals or agencies:
.
.
.
.
to provide information to:
(Name)
(Address)
Including records of:
__ Yes ___ No Family History
__ Other, as listed:
__ Yes ___ No Employment/Unemployment
.
__ Yes ___ No Educational Reports
.
__ Yes ___ No Alcohol/Drug Treatment
.
__ Yes ___ No Mental Health Services
.
__ Yes ___ No Medical/Psychiatric Treatment
.
Alcohol/Drug, Mental Health and Medical Records include all aspects of diagnosis, treatment, and prognosis. Educational records include both behavioral and progress reports.
I agree that the agencies and individuals listed above may share and exchange information about my family and my circumstances. ___ Yes ___ No
Purpose: The information received will be used to evaluate my situation and to plan for and coordinate services for me and my family, or for other purposes as specified:
.
This permission is good for one year or until:
I can cancel this at any time, but I understand that the cancellation will not affect any information that was already released before the cancellation. I understand that information about my case is confidential and protected by state and federal law. I approve the release of this information. I understand what this agreement means. I am signing on my own and have not been pressured to do so.
To those receiving information under this authorization: This information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.
This is a true copy of the original authorization document (Agency Staff Person)
DHR 2100 (Rev. 5/83)
For People Who Cannot Write
I understand this form and am completing it voluntarily. I cannot write. I am placing my mark by my name to sign this form.
My Mark:
Full Name of Client:
Date:
Witness #1
Address:
Witness #2
Address:
For People Who Cannot Read
I have read the form to the client. He/she understands it and signed it voluntarily.
Worker's Name
Signature
Date
* Explanation: Supplying the Social Security number is voluntary, and in general the refusal to supply the Social Security number cannot be used to deny services. However, it is necessary for identifying records for Employment and Vocational Rehabilitation information. In either case, if supplied, the Social Security number may be used to enforce agency regulations.
The worker should fill out this form for the client. Be sure the client understands it before signing. Encourage the client to ask questions about the form and what it allows.
Mail Requests. If this form is being used to request information by mail, be specific about what you need. If you have a series of questions, use a cover letter. The more clear you are in your request, the more likely you are to receive a prompt and accurate response. Do not ask for information you do not need.
Family Records. This release covers information about the person signing the form, minor children, and information about the family he/she supplied for the record. It would not cover information supplied by other adult family members unless they also sign a release.
Children. Minors can consent to medical treatment at age 15, mental, emotional or chemical, depending on treatment, at age 14. They may sign their own permission for release of information forms needed for such treatment.
Photocopying. Keep the original in the file and send copies to other agencies. The person making the photocopies should sign each copy at the bottom of the first page certifying it as a true copy. The agency receiving the authorization should reject it if there is not an original signature by the person who made the copy.
Redisclosure. Information received under this authorization should not be redisclosed to any party not identified on this form without specific written consent. Criminal penalties may apply to illegal disclosure. Federal regulations (42 C.F.R. Part 2) prohibit you from making any further disclosures of Alcohol and Drug information 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.
Revocation. If the person later cancels this authorization, write "revoked" and the method and date of revocation boldly across the form. Date and initial it, and keep it in the file. Federal regulations do not allow us to require that the revocation be in writing.
Duration. The authorization is valid for one year unless otherwise specified. Check to be sure that the release you are using is still current.
Guardianship/Custody. If the signer is a guardian, a copy of the guardianship paper must be attached when the request is sent. Similarly, if an agency has custody and their representative signs, the custody order should be included.
This is a Voluntary Form. However, clients should be given accurate information on how the refusal to allow the release of information will adversely affect eligibility determination or coordination of services. If the client decides not to sign, attempt to refer the family to a single service that may be able to help them without an exchange of information.
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