[Staff Use Only] Coping Partners Child Release of Information Form

[Staff Use Only] Coping Partners - Child (or disabled Adult) Release of Information Form
Client Last Name*
I hereby authorize the Clinician at Coping Partners:*
Enter Clinician's Name
To use, release, and exchange mental health and medical information and records obtained during the course of treatment of:
Client Name*

First NameLast Name
Date of Birth of Client*

MonthDayYear
Date
1. The information is to be disclosed/exchanged with Coping Partners & the following party:
Send Records to the Attention of:*
Phone Number (enter all zeros if you don't have phone #)*

Area CodePhone Number
Email (if you don't have an email enter 'none@none.com')*
example@example.com
2. Purpose: The purpose of the use or disclosure is for:*

Treatment PlanningOther
3. Persons Authorized and information to be used or disclosed:

The information to be used or disclosed by Coping Partners, its independent contractors, psychologists, social workers, providers and other employees includes only those items checked below. I understand that this authorization extends to all or any part of the records/information designated below which may include treatment for physical and mental illness, alcohol/drug abuse, sexually transmitted disease, HIV/AIDS test results or diagnoses.
The information to be used or released includes: (check any that apply)*

Psychological TestingEducation – Clinical ProgressEducation – IEP/School AssessmentsEducation – School AssignmentsMedication RecordsVerbal and Email Communication – No RestrictionsVerbal Communication Restrictions ________________Discharge SummaryPsychiatric EvaluationTherapist/Social Services Progress NotesTreatment PlansClinical Aftercare PlanOther
This authorization is limited to only that information requested above to be disclosed to or by Coping Partners. I/we hereby release Coping Partners from all legal responsibilities or liability that may arise from the use, disclosure or redisclosure of medical or other records and other health information in reliance on this authorization.
Mandated Recitals:
1. Expiration: I/we understand that unless I revoke the authorization earlier, this authorization will automatically expire on:*

MonthDayYear
Date (can be up to 2 years from the date it is signed)
2. Redisclosure: I/we understand that information used or disclosed in accordance with this authorization may no longer be protected by federal law, and could be used or redisclosed by the receiving party, pursuant to any agreement I may have with such party.

3. Refusal to sign: I/we understand that I/we may refuse to sign this authorization and the result would be that the records would not be disclosed.

4. Certification: The undersigned affirms that the identification that I have provided is true and correct.

5. Revocation: I/we have the right to stop the use or release of this information at any time if I do so in writing to Coping Partners although I/we understand that I/we cannot do anything about information already used or disclosed pursuant to this authorization.

6. Copy Received: I/we understand that I/we will receive a copy of this completed form.

7. Inspect and Copy: I/we understand that I/we have the right to inspect and copy the information to be disclosed.

8. Challenge: I/we understand that I/we have the right to challenge the accuracy of any information contained in the subject file.

9. Effect of Copies: I/we intend that fax, copies or electronic versions of this document shall carry the same force and effect as the original.

10. Alcohol/Substance Abuse Files: If any requested records contain information regarding alcohol or drug abuse treatment, these records are protected by Federal confidentiality rules. These rules prohibit further disclosure of this information unless further use or disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by Federal rules. A general authorization for the use or release of medical or other information is insufficient for this purpose. Federal rules restrict use of the information for criminal investigation or prosecution of any alcohol or drug abuse patient.
Name of Client*

First NameLast Name
Client Signature (Age 12 or older only - if younger than 12 yrs fill in NA)*

Clear
Date of Client Signature*

MonthDayYear
Date
Name of Witness (must be 18 yrs or above)*

First NameLast Name
Witness to Client Signature*

Clear
Date of Witness to Client Signature*

MonthDayYear
Date
Name of Personal Representative (Parent, Guardian, or Other Authorized Agent)*

First NameLast Name
Personal Representative Signature*

Clear
Date of Personal Representative Signature*

MonthDayYear
Date
Name of Witness to Personal Representative (must be 18 yrs or above)*

First NameLast Name
Witness to Personal Representative Signature*

Clear
Date of Witness to Personal Representative Signature*

MonthDayYear
Date
Should be Empty:

[Staff Use Only] Coping Partners - Child (or disabled Adult) Release of Information Form