Form JD-JM-187 "Juvenile Matters Victim's Designation of Receiver for Child's Hiv/Aids Test Results" - Connecticut

What Is Form JD-JM-187?

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

Form Details:

  • Released on October 1, 2010;
  • The latest edition provided by the Connecticut Superior Court;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-JM-187 by clicking the link below or browse more documents and templates provided by the Connecticut Superior Court.

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Download Form JD-JM-187 "Juvenile Matters Victim's Designation of Receiver for Child's Hiv/Aids Test Results" - Connecticut

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JUVENILE MATTERS
STATE OF CONNECTICUT
VICTIM'S DESIGNATION OF
Instructions To Victim:
SUPERIOR COURT
RECEIVER FOR CHILD'S
Send completed original and
www jud.ct.gov
HIV/AIDS TEST RESULTS
1 copy to the clerk of court.
JD-JM-187 New 10-10
Keep a copy for your records.
C.G.S. §§ 54-102a, 54-102b, 54-102C P.A. 10-43 § 41-42
Instructions To Clerk:
Retain original in the court file.
To: The Superior Court for Juvenile Matters
Address of court
Docket number
Name of child
Name of victim
Designation of Health Care Provider/HIV Counseling and Testing Site
I designate ("X" one)
the health care provider named below to receive the results of the court ordered HIV/AIDS test performed on the child and to
disclose the child's test results to me. I understand that the health care provider may charge me (or my insurance
company) for any costs associated with disclosing the child's test results to me and that I am financially responsible for
these costs. I also understand that I may be eligible for victim compensation for these costs and that I can contact the
Office of Victim Services at (888) 286-7347 for additional information about victim compensation.
Name, address and telephone number of health care provider
the HIV Counseling and Testing Site, funded by the State of Connecticut Department of Public Health, named below to receive
the results of the court ordered HIV/AIDS test performed on the child and to disclose the test results to me. I understand that
the services provided by the HIV counseling and testing site are free of charge and that no costs for any services
provided will be billed to me.
Name, address and telephone number of HIV counseling and testing site
Consent to Release Name and Address to Provider/HIV Counseling and Testing Site
Great care is taken by the court to protect all juvenile matters case information from disclosure. If you give the Court permission to give
your name and address to a health care provider or HIV counseling and testing site it is important for you to know that this information
may no longer be protected as confidential. Although the Court cannot protect your information after it is disclosed to a health care or
HIV counseling and testing site, there are several state and federal laws that protect the privacy of all information contained in a juvenile
matters case and HIV/AIDS test information and medical information that may prevent further disclosure of your name and address by
the health care provider or HIV counseling and testing site you have designated to receive this information.
I, (enter name of victim)
authorize the Superior Court for Juvenile
Matters to disclose my name and address, in writing, to the health care provider or HIV counseling and testing site designated above. The
purpose of this disclosure is to provide the above named health care provider or HIV counseling and testing site with the information for the
health care provider or HIV counseling and testing site to contact me to tell the results of the child's court ordered HIV/AIDS test to me.
I understand that I have the right to change my mind and withdraw this authorization to release my information by completing and filing
with the clerk of court the Withdrawal of Consent to Release Information provided below. I also understand that any such withdrawal of
authorization will not apply to information that the Court has already given to the health care provider or HIV counseling and testing site I
listed above in accordance with this release.
Date
Date
I have read and
Signed (Victim)
Signed (Parent/Guardian if minor)
understand the above
Withdrawal of Consent to Release Information
I (enter name of victim)
withdraw my permission for the Superior
Court for Juvenile Matters to disclose my name and address to the health care provider or HIV counseling and testing site I designated
on (date)
.
I understand that by (1) signing this form the Court will not release my name and address to the health care provider or HIV counseling
and testing site that I designated to receive the results of the Court ordered HIV/AIDS test of the child, and (2) the results will not be
provided to me by the Court's designee. I also understand that if the Court released the information to the designated health care
provider or HIV counseling and testing site before the Court received this withdrawal then this withdrawal is not valid.
Date
Date
Signed (Victim)
Signed (Parent/Guardian if minor)
I have read and
understand the above
Print Form
Reset Form
JUVENILE MATTERS
STATE OF CONNECTICUT
VICTIM'S DESIGNATION OF
Instructions To Victim:
SUPERIOR COURT
RECEIVER FOR CHILD'S
Send completed original and
www jud.ct.gov
HIV/AIDS TEST RESULTS
1 copy to the clerk of court.
JD-JM-187 New 10-10
Keep a copy for your records.
C.G.S. §§ 54-102a, 54-102b, 54-102C P.A. 10-43 § 41-42
Instructions To Clerk:
Retain original in the court file.
To: The Superior Court for Juvenile Matters
Address of court
Docket number
Name of child
Name of victim
Designation of Health Care Provider/HIV Counseling and Testing Site
I designate ("X" one)
the health care provider named below to receive the results of the court ordered HIV/AIDS test performed on the child and to
disclose the child's test results to me. I understand that the health care provider may charge me (or my insurance
company) for any costs associated with disclosing the child's test results to me and that I am financially responsible for
these costs. I also understand that I may be eligible for victim compensation for these costs and that I can contact the
Office of Victim Services at (888) 286-7347 for additional information about victim compensation.
Name, address and telephone number of health care provider
the HIV Counseling and Testing Site, funded by the State of Connecticut Department of Public Health, named below to receive
the results of the court ordered HIV/AIDS test performed on the child and to disclose the test results to me. I understand that
the services provided by the HIV counseling and testing site are free of charge and that no costs for any services
provided will be billed to me.
Name, address and telephone number of HIV counseling and testing site
Consent to Release Name and Address to Provider/HIV Counseling and Testing Site
Great care is taken by the court to protect all juvenile matters case information from disclosure. If you give the Court permission to give
your name and address to a health care provider or HIV counseling and testing site it is important for you to know that this information
may no longer be protected as confidential. Although the Court cannot protect your information after it is disclosed to a health care or
HIV counseling and testing site, there are several state and federal laws that protect the privacy of all information contained in a juvenile
matters case and HIV/AIDS test information and medical information that may prevent further disclosure of your name and address by
the health care provider or HIV counseling and testing site you have designated to receive this information.
I, (enter name of victim)
authorize the Superior Court for Juvenile
Matters to disclose my name and address, in writing, to the health care provider or HIV counseling and testing site designated above. The
purpose of this disclosure is to provide the above named health care provider or HIV counseling and testing site with the information for the
health care provider or HIV counseling and testing site to contact me to tell the results of the child's court ordered HIV/AIDS test to me.
I understand that I have the right to change my mind and withdraw this authorization to release my information by completing and filing
with the clerk of court the Withdrawal of Consent to Release Information provided below. I also understand that any such withdrawal of
authorization will not apply to information that the Court has already given to the health care provider or HIV counseling and testing site I
listed above in accordance with this release.
Date
Date
I have read and
Signed (Victim)
Signed (Parent/Guardian if minor)
understand the above
Withdrawal of Consent to Release Information
I (enter name of victim)
withdraw my permission for the Superior
Court for Juvenile Matters to disclose my name and address to the health care provider or HIV counseling and testing site I designated
on (date)
.
I understand that by (1) signing this form the Court will not release my name and address to the health care provider or HIV counseling
and testing site that I designated to receive the results of the Court ordered HIV/AIDS test of the child, and (2) the results will not be
provided to me by the Court's designee. I also understand that if the Court released the information to the designated health care
provider or HIV counseling and testing site before the Court received this withdrawal then this withdrawal is not valid.
Date
Date
Signed (Victim)
Signed (Parent/Guardian if minor)
I have read and
understand the above
Print Form
Reset Form