Authorization — Consent to Release Information

State of Colorado
Authorization — Consent to Release Information to Mesa County Partners
Youth's Information
Name

First NameLast Name
MI
Physical Address
City
State
ZIP
Permanent Address (if different than physical address)
City
State
ZIP
Email
example@example.com
Phone
Format: (000) 000-0000.
DOB
Type of Identifier:OtherDLState IDIdentifier #:
Child Welfare CaseCase ReportJDPassport
State IDIdentifier #
Role
Consenter/Person Authorizing Consent (if person above is a minor)
Name

First NameLast Name
MI
Physical Address
City
State
ZIP
Permanent Address (if different than physical address)
City
State
ZIP
Email
example@example.com
Phone
Format: (000) 000-0000.
DOB
Type of Identifier:OtherDLState ID
Child Welfare CaseCase ReportJDPassport
Identifier #
Role
Authorizes
DHS
DHS/ Division of Youth CorrectionsLEAProbation Juvenile, County,Juvenile Assessment CtrCourt (Juvenile, County, Municipal)School (Private or District)SB94DHS/ Office of Behavioral HealthService ProviderDiversionDA
Office
Other
To Release Information to
DHS
DHS/ Division of Youth CorrectionsLEAProbation Juvenile, County,Juvenile Assessment CtrCourt (Juvenile, County, Municipal)School (Private or District)SB94DHS/ Office of Behavioral HealthService ProviderDiversionDA
Office
Service Provider
To Receive Information From
DHS
Office
DHS/ Division of Youth CorrectionsLEAProbation Juvenile, County,Juvenile Assessment CtrUse only last four digits of SSN if used.School (Private or District)SB94DHS/Office of Behavioral HealthUse only last four digits of SSN if used.DiversionDA
Service Provider
AdjudicationCoordination of ServicesInsurance (Health/Life)PlacementTreatmentAssessmentIntakeInterdisciplinary Team StaffingPretrialOther
Type of Information Requested
Education
Treatment HistoryCurrent PrescriptionsMH AssessmentProbation HistoryHuman Service RecordsOther RecordsEvaluationsMedical HistoryMH Treatment HistoryProbation RecordsChild Welfare HistorySchool Attendance RecordsImmunizationsDiagnosisPolice Reports/RecordsSchool Behavior ReportsOther Court RecordsIEP’s/504
Medical
Mental Health
Justice Agency
Other (Please Specify)
Preparer’s Initials
Consenter’s Initials
Date Range of Youth Records:
From: Month
Day
Year
To : Month
Day
Year
Date Range of Authorization/Consent:From:Month
Day
Year
Month: To
Day
Year
Fax Email Telephone In Person OtherDate Range of Authorization/Consent:From:Month:Day:Year:Month: To :
Fax Email Telephone In Person Other
Format: (000) 000-0000.
Signature of person authorizing consent: Date: (MM/DD/YYYY )

MonthDayYear
Date
By my signature, I consent to the release of information contained on this form for use by the requesting agencycies I understand that my records are protected under Federal and State regulations governing confidentiality, 42 part 2, HIPAA , and FERPA and cannot be released without my written consent unless otherwise provided for by the regulations. I understand that any agency or individual using the confidential information or records obtained will take all necessary steps to protect the confidentiality of the above named juvenile/child’s identity. I acknowledge that I have been informed of my rights to refuse to sign this form, and any conditions related to my consent or refusal, and that I am entitled to receive a copy of the signed form.
Type or print name
Date: (MM/DD/YYYY )

MonthDayYear
Date
Day:
Consenter declined release of information. Provided to Client Date Declined: MM/DD/YYYY

MonthDayYear
Date
staff initial Copy
Type or print name
Should be Empty:

State of Colorado

Authorization — Consent to Release Information to Mesa County Partners

Youth's Information

Authorizes

To Release Information to

To Receive Information From

Type of Information Requested

Education

Medical

Mental Health

Justice Agency

Date Range of Youth Records: