The Consent to Release includes any health information or medical records, including my alcohol and/or drug treatment records, which may be a part of the above-stated records, protected under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C. F. R. Pts. 160 & 164 and Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2. I understand such records cannot be disclosed without my written consent, unless otherwise provided for in the regulations. I understand that none of the agencies listed herein may condition my treatment on whether or not I sign this form.
Purpose of Consent to Release. This consent to release is intended for the purpose of allowing release of information critical to allow certain agencies, part of the committee formed pursuant to 04 H.B. 1451 (“1451 Committee”), and pursuant to memorandums of understanding between those agencies and the Logan County Department of Human Services, to coordinate and manage the provision of services to children and families who would benefit from integrated multi–agency services. This Consent to Release authorizes the sharing of information among the listed entities, many or all of which are authorized to view such information pursuant to applicable state or federal law.
This Consent to Release automatically ends one year from the date I sign this form, or when the sharing of information is no longer needed to manage or provide services to me, my child(ren), or wards, or when I revoke my consent, whichever is sooner, except to the extent that the program or person authorized to make the disclosure has already acted in reliance on this consent. I understand I may revoke this authorization at any time by signing the revocation statement below and providing this document to the agencies listed in this Consent to Release. Agencies and providers who are listed in this Consent to Release and request information under this release may use a copy, digital file, or facsimile (FAX) of this form in place of the original signed consent form.
I agree that this information may be redisclosed to all agencies listed if necessary to fulfill the purpose of the Consent to Release.