Form JV-226 "Authorization to Release Health and Mental Health Information" - California

What Is Form JV-226?

This is a legal form that was released by the California Superior Court - a government authority operating within California. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2013;
  • The latest edition provided by the California Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;

Download a fillable version of Form JV-226 by clicking the link below or browse more documents and templates provided by the California Superior Court.

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Download Form JV-226 "Authorization to Release Health and Mental Health Information" - California

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To keep other people from seeing what you entered on your form, please press the Clear This Form button at the end of the form when finished.
Authorization to Release Health
JV-226
Fill in court name and street
and Mental Health Information
address:
This form authorizes the release of the child’s health and/or
Superior Court of
mental health records to the child welfare agency to ensure
California, County of
that the child receives appropriate and effective services. It
also allows the agency to carry out its case management
responsibilities; to monitor treatment, health-care operations,
and billing and payment; and to inform the court of the child’s
medical and/or mental health needs. This form complies with
the Health Insurance Portability and Accountability Act
Fill in child's name and date of
birth:
(HIPAA), Confidentiality of Medical Information Act
Child’s Name:
(CMIA), and Lanterman-Petris-Short (LPS) Act.
The parent, legal guardian, or Indian custodian may only
Date of Birth:
complete items
,
,
,
,
,
, and
.
1
2
3
6
7
8
9
The child may only complete items
,
,
,
,
,
,
1
2
4
5
6
7
and
.
8
Case Number:
I am the
1
a.
Parent
b.
Legal guardian
c.
Indian custodian
d.
Child, and I am eligible to consent
I give the following child welfare agencies and individuals permission to release health
2
information about
me
the child
3
I am the parent, legal guardian, or Indian custodian and I authorize release of the
following medical information. Mental health information contained in the medical file
may not be released.
I understand that I may refuse to sign this form. I understand that the child cannot be
denied treatment just because I choose not to sign. (Check all that apply):
a.
Diagnoses
d.
Immunizations
g.
None
b.
e.
Medical histories
Lab reports
h.
c.
Medications
f.
X-ray reports
Judicial Council of California, www.courts.ca.gov
JV-226,
Page 1 of 3
Authorization to Release Health and
Revised July 1, 2013, Optional Form
Mental Health Information
(Dependency)
To keep other people from seeing what you entered on your form, please press the Clear This Form button at the end of the form when finished.
Authorization to Release Health
JV-226
Fill in court name and street
and Mental Health Information
address:
This form authorizes the release of the child’s health and/or
Superior Court of
mental health records to the child welfare agency to ensure
California, County of
that the child receives appropriate and effective services. It
also allows the agency to carry out its case management
responsibilities; to monitor treatment, health-care operations,
and billing and payment; and to inform the court of the child’s
medical and/or mental health needs. This form complies with
the Health Insurance Portability and Accountability Act
Fill in child's name and date of
birth:
(HIPAA), Confidentiality of Medical Information Act
Child’s Name:
(CMIA), and Lanterman-Petris-Short (LPS) Act.
The parent, legal guardian, or Indian custodian may only
Date of Birth:
complete items
,
,
,
,
,
, and
.
1
2
3
6
7
8
9
The child may only complete items
,
,
,
,
,
,
1
2
4
5
6
7
and
.
8
Case Number:
I am the
1
a.
Parent
b.
Legal guardian
c.
Indian custodian
d.
Child, and I am eligible to consent
I give the following child welfare agencies and individuals permission to release health
2
information about
me
the child
3
I am the parent, legal guardian, or Indian custodian and I authorize release of the
following medical information. Mental health information contained in the medical file
may not be released.
I understand that I may refuse to sign this form. I understand that the child cannot be
denied treatment just because I choose not to sign. (Check all that apply):
a.
Diagnoses
d.
Immunizations
g.
None
b.
e.
Medical histories
Lab reports
h.
c.
Medications
f.
X-ray reports
Judicial Council of California, www.courts.ca.gov
JV-226,
Page 1 of 3
Authorization to Release Health and
Revised July 1, 2013, Optional Form
Mental Health Information
(Dependency)
Case Number:
Child’s name:
If the child is between 12 and 18 years old, the child may authorize release of the following
4
information.
I discussed the contents of this form with my attorney before deciding whether or not to
sign this form. I understand that I may refuse to sign this form. I understand that I
cannot be denied treatment just because I choose not to sign.
I am the child and I authorize the following information to be disclosed (check all that
apply):
a.
e.
HIV information, including test
Records regarding infectious,
results
contagious, or communicable disease
b.
if law or regulation requires the
Mental health diagnoses
disease or condition to be reported to
c.
Outpatient mental health treatment
the local health officer
or counseling records
d.
f.
Records regarding sexually
None
transmitted diseases
Only the child, regardless of his or her age, may authorize release of the following
5
information.
I discussed the contents of this form with my attorney before deciding whether or not to
sign this form. I understand that I may refuse to sign this form. I understand that I
cannot be denied treatment just because I choose not to sign.
I am the child, and I authorize the following information to be disclosed (check all that
apply):
None
a.
Pregnancy records
d.
b.
Reproductive health records
c.
Sexual assault treatment records,
if the child consented to this treatment
I give permission to release
my
the child’s
health information specified by the
6
checked boxes in items 3, 4, and 5 and to discuss them with (name of child welfare
agency):
.
7
I understand that the child welfare agency may share or be required to share
my
the
child’s
health and/or mental health information with certain persons or agencies for
purposes of treatment, health-care operations, billing and payment, or as otherwise required
by law, without having to ask for my permission.
I understand that if this health and mental health information is disclosed to someone who is
not legally required to keep it confidential, it may be redisclosed and may no longer be
protected.
JV-226,
Revised July 1, 2013
Page 2 of 3
Authorization to Release Medical and
Mental Health Information
(Dependency)
Case Number:
Child’s name:
a.
I request a copy of this form.
8
b.
I am the child and understand that I do not have to give this form to my parent or
legal guardian.
c.
I do not want a copy of this form.
d.
I request a copy of the records that will be released.
I understand that I may revoke this authorization by writing to (name and address of
9
person to whom revocation should be directed):
Once this person receives my written request, this authorization will be revoked, but only
to the extent that the authorization has not already been relied upon to release health
information.
This authorization automatically ends one year from date of signature.
10
This form is not intended to abrogate the rights of court-appointed counsel for the child to
11
access records pursuant to Welfare and Institutions Code section 317(f) or court order.
Date:
(TYPE OR PRINT NAME OF
(SIGNATURE)
PARENT/LEGAL GUARDIAN)
(SIGNATURE)
(TYPE OR PRINT NAME OF CHILD )
IMPORTANT: PLEASE READ
The health-care provider may refuse to release the records if he or she determines
that access to the child’s records would have a detrimental effect on the provider’s
professional relationship with the child or the child’s physical safety or psychological
well-being.
JV-226,
Page 3 of 3
Revised July 1, 2013
Authorization to Release Medical and
Mental Health Information
(Dependency)
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