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Form Cs-0076 - Release Of Health Information -Tennessee Department Of Children'S Services

RELEASE OF HEALTH INFORMATION

TENNESSEE DEPARTMENT OF CHILDREN’S SERVICES

CONSENT AND AUTHORIZATION TO RELEASE INFORMATION OR HEALTH RECORDS UNDER THE PROTECTION

OF FEDERAL LAW, TITLE 42, CFR CHAPTER II PART II

Name: ____________________________________________________________

Number: ____________________

first

middle

last

Birthdate: ____________________ Social Security No. __________________________

Sex: _______________

Parent’s Name: _____________________________________________________________________________________

Pursuant to Federal Guidelines concerning my right to confidentiality, I, _________________________________________

(name of client)

authorize _________________________________________ to release my health records or information concerning my

(name of specific person or organization)

health records to ____________________________________________________________________________________

(name of specific person or organization)

I specifically consent only to the release of information or health records pertaining to:

The following information:

__Behavioral

___Medical

? ___Dental

___All of the below

___ prior assessments

___ recommendations

___ closing summaries

___ progress notes

___ treatment provided

___ medical

___ opinions regarding parent competence

___ other relevant information, medical or psychological

I understand that I may revoke this consent to release of information at any time; however, I also understand that any

release which has been made prior to my revocation and which was made in reliance upon this authorization shall not

constitute a breach of my right to confidentiality. Unless I revoke this authorization prior to such time, this authorization to

release information shall expire when:

_________________________________________________________________________

__________________________________________________________________________________________________

(date, event, condition or expiration)

At that time no express revocation shall be needed to terminate my consent; however revocation of consent at any other

time must be provided in writing.

client’s signature

date

witness

date

(A youth aged 16 or older may sign for themselves; the case manager or foster parent may sign for any custodial youth in

their care.)

Custodial agent

date

Original:

Recipient

Copy:

Health Record

CS-0076

Form Cs-0076 - Release Of Health Information -Tennessee Department Of Children'S Services

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