Form CW 61 Authorization to Release Medical Information - California

Form CW61 is a California Department of Social Services form also known as the "Authorization To Release Medical Information". The latest edition of the form was released in July 1, 2001 and is available for digital filing.

Download a fillable PDF version of the Form CW61 down below or find it on California Department of Social Services Forms website.

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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DEAR HEALTH CARE PROVIDER:
The California Work Opportunity and Responsibility to Kids (CalWORKs) program requires that non-exempt individuals
participate in work, training, or educational activities for 32 or 35 hours (for one or two-parent households, respectively)
per week. CalWORKs participants must make “satisfactory progress” in their activities.
We ask your help in evaluating this individual by providing us with information regarding how his/her mental or physical
condition will affect the ability to participate in a work/training program. With this information, we can better assign the
participant to an appropriate activity. It will also help us to determine if the participant’s condition will enable him/her to
participate or successfully complete 32 or 35 hours per week of work and/or training requirements.
Please complete Section 2 of the attached form and sign (or have your authorized representative sign) the Certification in
Section 3. Please also complete the Physical Capacities and/or Mental Capacities form(s), as appropriate.
Thank you for your assistance.
WORKER NAME
FAX NUMBER
WORKER PHONE NUMBER
CW 61 (7/01) COVERSHEET - REQUIRED FORM - SUBSTITUTE PERMITTED
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
DEAR HEALTH CARE PROVIDER:
The California Work Opportunity and Responsibility to Kids (CalWORKs) program requires that non-exempt individuals
participate in work, training, or educational activities for 32 or 35 hours (for one or two-parent households, respectively)
per week. CalWORKs participants must make “satisfactory progress” in their activities.
We ask your help in evaluating this individual by providing us with information regarding how his/her mental or physical
condition will affect the ability to participate in a work/training program. With this information, we can better assign the
participant to an appropriate activity. It will also help us to determine if the participant’s condition will enable him/her to
participate or successfully complete 32 or 35 hours per week of work and/or training requirements.
Please complete Section 2 of the attached form and sign (or have your authorized representative sign) the Certification in
Section 3. Please also complete the Physical Capacities and/or Mental Capacities form(s), as appropriate.
Thank you for your assistance.
WORKER NAME
FAX NUMBER
WORKER PHONE NUMBER
CW 61 (7/01) COVERSHEET - REQUIRED FORM - SUBSTITUTE PERMITTED
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
STATE OF CALIFORNIA-HEALTH AND HUMAN SERVICES AGENCY
COUNTY USE ONLY
CASE NAME:
CASE NUMBER:
AUTHORIZATION TO RELEASE
MEDICAL INFORMATION
WORKER NAME:
WORKER NUMBER:
Section I must be completed by the patient/client. Sections 2 and 3 are to be completed by the type of provider (or his/her authorized
representative) checked below: (County worker to check appropriate box below.)
Licensed physician or certified psychologist.
Health care professional licensed or certified by a state to diagnose/treat physical or mental impairments affecting the ability to
work or participate in education/training activities including, but not limited to, medical doctors, osteopaths, chiropractors, and
licensed/certified psychologists.
SECTION 1. PATIENT/CLIENT INFORMATION AND AUTHORIZATION TO RELEASE INFORMATION
SECTION 1. PATIENT/CLIENT INFORMATION AND AUTHORIZATION TO RELEASE INFORMATION
NAME OF PATIENT/CLIENT (LAST, FIRST, MIDDLE)
SEX (CIRCLE)
BIRTH DATE
SOCIAL SECURITY NUMBER
AGE(S) OF CHILD(REN) IN HOME
-
-
-
-
M
F
I authorize_____________________________________ of ___________________________________________________________
NAME OF PROVIDER
CLINIC OR MEDICAL GROUP
to release information to the county welfare department from my records on the conditions checked below:
Physical Condition
Mental Condition
Other (Describe)_________________________________________
I know this authorization may be used by the county welfare department for up to one year to obtain medical information. I may revoke
this authorization at any time, except for information that has already been given to the welfare department. This information is needed
by the county welfare department to determine eligibility for cash aid or food stamps. It is also needed to decide the type of work or
training activities that I can take part (participate) in, and the CalWORKs services that I need. This information will be kept in the case
file and will not be disclosed without my signed consent for each disclosure unless the disclosure is specifically required or allowed by
law. I have read this form (or had this form read to me) after it was completed. I know I can get a copy of this form if I ask for it.
PATIENT/CLIENT SIGNATURE
RELATIONSHIP TO PATIENT, IF NOT SELF
DATE SIGNED
SIGNATURE OF WITNESS TO MARK, INTERPRETER, OR PERSON ACTING FOR PATIENT/CLIENT
DATE SIGNED
SECTION 2. STATEMENT OF PROVIDER
SECTION 2. STATEMENT OF PROVIDER
The information requested is needed to evaluate eligibility for public assistance for the person named above and to determine his/her
work assignment. Please answer the following questions as indicated by check mark:
Questions 1 through 5
Question 6
Question 7
1.
Does the patient have a medically verifiable condition that would limit or prevent him/her
from performing certain tasks? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If YES, complete the rest of this form, and the Physical Capacities and/or Mental Capacities form (if attached), as appropriate.
If NO, just complete the Health Care Provider Certification Section below.
2.
Onset Date of Condition ____________. The condition is
Chronic
Acute, expected to last until_________________
3.
Is the patient actively seeking treatment?
YES
NO
Next appointment date __________________________________
4.
Is this person able to work? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
If YES, how many hours per day?______________
5.
Does this person have any limitations that affect his/her ability to work or participate in education or training? .
YES
NO
6.
It is necessary to determine whether child care needs to be provided to enable
the other parent to work. Does the patient’s condition prevent him/her from providing care for
the child(ren) in the home? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
YES
NO
7.
Does the patient’s condition require someone to be in the home to care for him/her? . . . . . . . . . . . . . . . . . . . .
YES
NO
SECTION 3. PROVIDER CERTIFICATION
SECTION 3. PROVIDER CERTIFICATION
DATE SIGNED
SIGNATURE OF PROVIDER OR PROVIDER’S AUTHORIZED REPRESENTATIVE
PRINT NAME AND TITLE/SPECIALTY
PHONE NUMBER
(
)
STREET ADDRESS
(MAILING ADDRESS, IF DIFFERENT)
CITY
STATE
ZIP CODE
CW 61 (7/01) REQUIRED FORM - SUBSTITUTE PERMITTED

Download Form CW 61 Authorization to Release Medical Information - California

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