Release, Disclosure and Exchange of Information

Release, Disclosure and Exchange of Information

Completing this release is voluntary and will not impact your eligibility for WIC or any other program/entity identified on this form.
Parent/Guardian Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Are you currently pregnant?*

YesNoN/A
Children's Information for WIC (Click "Add Row" to add another child)
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Email for a copy of this form
example@example.com
Agencies - Releasing To and From

I hereby request, consent to and authorize the mutual disclosure and exchange of information and records concerning the above-named participant(s) by and between the organizations below:
Select the agencies for information to be released FROM:

Healthcare ProviderWIC Program (outside MT)Home Visiting ProgramsFamily OutreachChild & Family Services (CFS)/DPHHS (Foster Care)Childcare provider (including Head Start/Early Head Start)Other
Healthcare Provider (please fill out for each person by clicking on "add row"):*
WIC Program - Outside of Montana

Program NameStateCounty
Home Visiting (please select those that apply)

Nurse Family Partnerships (NFP)Parents as Teachers (PAT)Safe CareThe Montana Asthma ProgramFamily Spirit
CFS/DPHHS Case Manager's Name

First NameLast Name
Childcare Providers Information

Name of childcare provider or facilityLocation
Select the agencies for information to be released TO:

Healthcare ProviderWIC Program (outside MT)Home Visiting ProgramsFamily OutreachChild & Family Services/DPHHS (Foster Care)Childcare provider (including Head Start/Early Head Start)Other
Healthcare Provider (please fill out for each person by clicking on "add row"):*
WIC Program - Outside of Montana

Program NameStateCounty
Home Visiting (please select those that apply)

Nurse Family Partnerships (NFP)Parents as Teachers (PAT)Safe CareThe Montana Asthma ProgramFamily Spirit
CFS/DPHHS Case Manager's Name

First NameLast Name
Childcare Providers Information

Name of childcare provider or facilityLocation
The information that may be released from my records includes (i.e., the purpose):*

Any information from the record(s) that is requested by the receiving provider/program in the scope of their care and/or services of the participant(s) listed.Only information related to:
Release is Valid Until*

1 year from the date signedOther date (specify)
The purpose for the disclosure and exchange of information is at my request and to facilitate the delivery of services, including service and care coordination.
The form is being filled out by (please select all that apply):*

SelfParent of minor childLegal GuardianPower of AttorneyOther Personal Representative
Date*

MonthDayYear
Date
Signature*

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*Minors are authorized by Montana law (§ 41-1-401,et seq., MCA) to both (1) consent to the provision of health care services and (2) control access to protected health care information under certain limited circumstances (i.e., pregnancy, sexually transmitted disease, or substance and alcohol abuse). Any utilization of this form based on the signature of a minor student should be carefully reviewed by the agency to ensure such circumstances are applicable.
WIC Non-Discrimination Statement: This institution is an equal opportunity provider.
Should be Empty:

Release, Disclosure and Exchange of Information

Agencies - Releasing To and From

The purpose for the disclosure and exchange of information is at my request and to facilitate the delivery of services, including service and care coordination.