Form Dcbs-1 - Informed Consent And Release Of Information And Records printable pdf download

DCBS-1

COMMONWEALTH OF KENTUCKY

(R. 10/10)

Cabinet for Health and Family Services

Department for Community Based Services

INFORMED CONSENT AND RELEASE OF INFORMATION AND RECORDS

Name _________________________________________________________

SSN ______________________________

I understand to help my family and me get the services we need the Department for Community Based Services (DCBS) and other

agency staff persons may need to share information and records in order to provide or verify eligibility for these services. By signing this

form, I give DCBS staff or staff of another agency, authorized to act on behalf of DCBS, permission to get any information needed to see

if I am eligible for any assistance program. I also give permission for DCBS and the following agencies or persons listed below to share

information and records with one another about services, benefits or treatment provided to me and my family:

Name of Agency or Individual

My consent includes the following information and records (please put your initials beside each checked item that you consent to):

____ Medical and Physical Health Records (not HIV or AIDS)

____ Behavioral Health and Psychiatric Records (not Drug or Alcohol Abuse Patient Records or Psychotherapy Notes)

____ Psychosocial History

_x__ Housing Records

____ Psychological Test Results

_x__ Residential Records

X__ Child Care Records

_x__ Child Support/ Spousal Support Records

____ Student School Records

_x__ SNAP Records

____ Long-term Facility and Alternate Care Records

_x__ K-TAP Records

____ Statement of Legal Status and Custody

_ x__Medicaid Records

____ Home Care and Home Health Records

____ Child Protective Services Records

____ Spouse Abuse and Rape Crisis Center Records

____ Adult Protective Services Records

____ Senior Program Provider Records

_x___Financial Records

____ Homeless Shelter Records

_x___Employment Records

____ Court Records

____ Other____________________________

This consent applies to the following members of my family for whom I have the legal authority to consent:

Member Name

SSN

Relationship

Member Name

SSN

Relationship

I understand that:



This authorization will be in effect for a period of __12 months__

from the signature date.

(not to exceed 12 months)



I may revoke this consent at any time in writing unless action has already been taken based on my consent.



DCBS will not condition treatment, payment, enrollment or eligibility for benefits on receipt of this form. Signing this form is voluntary,

but failing to sign it, or revoking it before the necessary information is obtained, could prevent an accurate or timely response and

could result in denial or loss of benefits.



Information may be disclosed with the other DCBS Divisions to assist in obtaining the requested services.



Information disclosed to DCBS may no longer be protected by the health information privacy provisions of 45 CFR Parts 160 and

164 pursuant to the Health Insurance Portability and Accountability Act (HIPAA).



Information may be disclosed by DCBS without my consent if authorized by State Law or Federal Laws such as the Privacy Act or

42 CFR Part 2 or to comply with laws regarding mandatory reporting of suspected abuse, neglect or exploitation, or assessment that

there is a danger of serious harm to self or others.



I have received a copy of this form. I may also request a copy of the information retained with it.

Signature _________________________________________________________________

Date _____________

[ ] Client

[ ] Parent

[ ] Legal Guardian

[ ] Other (specify) _____________________________________________________

Signature ________________________________________________________________

Date _____________

[ ] Client

[ ] Parent

[ ] Spouse

[ ] Legal Guardian

[ ] Other (specify) ___________________________________________

Witness Signature _________________________________________________________

Date _____________

[ ] DCBS worker (specify program area)_______________________[ X ] Other agency staff (specify) Child Care Assistance Program

Form Dcbs-1 - Informed Consent And Release Of Information And Records

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