Family Connections, LLC - DOC by Y1CSu7R


									                             Family Connections, LLC
                      Authorization for Release of Information
Name: ____________________________ Date of Birth: ____________________________

 I authorize Family Connections, LLC to                                I authorize Family Connections, LLC to
  release information both verbally and in                               obtain information both verbally and in
  writing to:                                                            writing from:

 ________________________________                        AND/OR          ________________________________
 Name of Provider or Facility                                            Name of Provider or Facility
 ________________________________                                        ________________________________
 Address                                                                 Address
 ________________________________                                        ________________________________
 Phone #/Fax # (include area code)                                       Phone #/Fax # (include area code)

Purpose of this Request: (check one)
Healthcare         Treatment Planning                         Education                  Employment
Personal                       Extracurricular                Housing                    Other ____________

Type of Records Authorized:
      Psychiatric/Psychological Evaluation and/or Treatment
           Drug/Alcohol Evaluation and/or Treatment

Specific Information Authorized: (select one or more as appropriate)
Assessments                       Progress Notes           IEP/Report Cards/Transcripts
Discharge Summary                            Treatment Plans/Goals               Treatment Summary
Other        _______________________________________________________________________
              Please describe

I authorize the periodic use/disclosure of the information described above to the
person/provider/organization/facility/program(s) identified as often as necessary to fulfill the purpose
identified in this document. My authorization will expire:
           120 days from this date.                   Other: _______________________

The person signing this form has the right to receive a copy of the consent form. A copy of this form
has been requested and received:
           Yes No Initials: _____

I understand that I may revoke this authorization at any time by notifying Family Connections, LLC in writing. I
understand that my alcohol and/or drug treatment records are protected under State and Federal Confidentiality
regulations (Chapter 899 of the Connecticut General Statutes and Title 42 of the U.S. Code and “HIPAA” Act of
1996, 45 C.F.R. pts 160 & 164, Privacy and Security regulations) and cannot be disclosed without my written
consent unless otherwise provided for in the regulations. I also understand that I may revoke this consent at any
time except to the extent that action has been taken in reliance on it (e.g. probation, parole, etc.) and in any event
this consent expires in 180 days automatically or as described above.

Signature of Parent/Legal Guardian: _______________________ Date: ___________________
                     PO Box 768 • Granby, CT 06035 • Phone: 866-573-3782 • Fax: 855-573-3782
           • rev. 1/26/2012

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