Form DCF-460 MDE "Multi-Disciplinary Evaluation Child/Youth Permission for Release of Information" - Connecticut

What Is Form DCF-460 MDE?

This is a legal form that was released by the Connecticut State Department of Children and Families - 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 August 1, 2014;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • 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 DCF-460 MDE by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Children and Families.

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Download Form DCF-460 MDE "Multi-Disciplinary Evaluation Child/Youth Permission for Release of Information" - Connecticut

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Connecticut Department of Children and Families
MULTI-DISCIPLINARY EVALUATION CHILD/YOUTH PERMISSION FOR RELEASE OF INFORMATION
DCF-460 MDE
8/2014 (New)
Page 1 of 1
Instructions:
Forward the original to the MDE Clinic and file a copy in the medical section of the
Uniform Case Record.
Last Name Of Child:
First Name Of Child
Date Of Birth:
Link #:
As parent/legal guardian/designee of the Commissioner of Children and Families,
I give medical permission and informed consent to conduct the MDE
Last Name:
First Name:
Title, if applicable:
Date:
Relationship To Child:
DCF Office & Address:
Please Select one
Please Select DCF Office
Name of Requesting DCF Social Worker:
DCF Social Worker's Phone Number:
MDE Clinic Name & Address:
Fax #:
Please Select One
Authorization to Release Medical Information
The parent/legal guardian/designee of the Commissioner of the Connecticut Department of Children and
Families authorize the above-named clinic to use and disclose the above-named child's protected health
information gathered during the MDE, to obtain payment, and to carry out health care operations. The
above named child/youth's protected health information may be disclosed to their health plan and/or
its agents as necessary to verify benefits, authorize services, and process medical/dental claims. The
protected health information may be disclosed to the Department of Children and Families, and other
persons or health care providers or institutions involved in the MDE evaluation. The above named
child/youth's protected health information may also be disclosed to outside agencies involved in his/her
continuing care and/or for emergency care purposes. The child/youth's protected health information
may also be disclosed to the child's primary care physician and other health care providers for continuing
care. The child/youth's protected health information may include mental health and medical/dental
information or any information pertaining to the examination, treatment, history, which may include
Psychiatric, HIV/AIDS, infectious disease, alcohol and/or drug information, coded medical/dental
information and charges to my health plan and/or their acting intermediaries and/or agents.
I understand that refusal to sign this authorization form will not affect my right to obtain present and
future services from DCF, except where disclosure of the records requested is necessary for services. I
also understand that I may revoke this authorization by notifying DCF in writing. A revocation of this
authorization will not apply to any records disclosed before the authorization is revoked. The information
disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer
protected by federal law.
For a child/youth between the ages of 13 and 17, no information pertaining to substance
abuse or reproductive health may be released without a separate release of information
signed by the child/youth (DCF-460-MDE-A).
The signature below indicates informed consent and medical permission to conduct the MDE and the
release of medical information.
Last Name:
First Name:
Title, if applicable:
Signature:
Relationship To Patient:
Date:
Connecticut Department of Children and Families
MULTI-DISCIPLINARY EVALUATION CHILD/YOUTH PERMISSION FOR RELEASE OF INFORMATION
DCF-460 MDE
8/2014 (New)
Page 1 of 1
Instructions:
Forward the original to the MDE Clinic and file a copy in the medical section of the
Uniform Case Record.
Last Name Of Child:
First Name Of Child
Date Of Birth:
Link #:
As parent/legal guardian/designee of the Commissioner of Children and Families,
I give medical permission and informed consent to conduct the MDE
Last Name:
First Name:
Title, if applicable:
Date:
Relationship To Child:
DCF Office & Address:
Please Select one
Please Select DCF Office
Name of Requesting DCF Social Worker:
DCF Social Worker's Phone Number:
MDE Clinic Name & Address:
Fax #:
Please Select One
Authorization to Release Medical Information
The parent/legal guardian/designee of the Commissioner of the Connecticut Department of Children and
Families authorize the above-named clinic to use and disclose the above-named child's protected health
information gathered during the MDE, to obtain payment, and to carry out health care operations. The
above named child/youth's protected health information may be disclosed to their health plan and/or
its agents as necessary to verify benefits, authorize services, and process medical/dental claims. The
protected health information may be disclosed to the Department of Children and Families, and other
persons or health care providers or institutions involved in the MDE evaluation. The above named
child/youth's protected health information may also be disclosed to outside agencies involved in his/her
continuing care and/or for emergency care purposes. The child/youth's protected health information
may also be disclosed to the child's primary care physician and other health care providers for continuing
care. The child/youth's protected health information may include mental health and medical/dental
information or any information pertaining to the examination, treatment, history, which may include
Psychiatric, HIV/AIDS, infectious disease, alcohol and/or drug information, coded medical/dental
information and charges to my health plan and/or their acting intermediaries and/or agents.
I understand that refusal to sign this authorization form will not affect my right to obtain present and
future services from DCF, except where disclosure of the records requested is necessary for services. I
also understand that I may revoke this authorization by notifying DCF in writing. A revocation of this
authorization will not apply to any records disclosed before the authorization is revoked. The information
disclosed pursuant to this authorization may be subject to re-disclosure by the recipient and is no longer
protected by federal law.
For a child/youth between the ages of 13 and 17, no information pertaining to substance
abuse or reproductive health may be released without a separate release of information
signed by the child/youth (DCF-460-MDE-A).
The signature below indicates informed consent and medical permission to conduct the MDE and the
release of medical information.
Last Name:
First Name:
Title, if applicable:
Signature:
Relationship To Patient:
Date: