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

What Is Form DCF-460 MDE-A?

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-A 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-A "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-A
8/2014 (New)
Page 1 of 1
Instructions:
Please have the child/youth (between ages 13 and 17) read and sign this document
granting permission for release of information pertaining to substance abuse,
reproductive health and/or medical information.
Last Name Of Child:
First Name Of Child
Date Of Birth:
Link #:
I hereby give medical permission and informed consent to the following Provider/Clinic:
MDE Clinic Name & Address:
Fax #:
Please Select One
Authorization to Release Medical Information
to disclose to the Department of Children and Families any information learned from my Multi-
Disciplinary Evaluation about substance abuse (alcohol/drug use and treatment) and reproductive
health (sexual activity, sexually transmitted diseases and birth control) information.
During my evaluation, some questions may be asked about my alcohol and drug use and treatment
and reproductive health. I understand this information will be shared with DCF, including the social
workers. They will keep this personal information confidential and will not share it with anyone else
unless given permission by me or my lawyer, or unless ordered by a judge. The purpose of this
authorization/disclosure is to provide information to DCF for use in case planning.
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.
If I change my mind about this authorization, I understand it will not apply to any information already
disclosed. I also understand the information that is disclosed to DCF may be re-disclosed according
to federal law.
The signature below indicates informed consent and medical permission to conduct the MDE and the
release of medical information by the child or youth
Last Name of Child/Youth:
First Name: of Child/Youth
Signature of Child/Youth Granting Permission:
Date:
Connecticut Department of Children and Families
MULTI-DISCIPLINARY EVALUATION CHILD/YOUTH PERMISSION FOR RELEASE OF INFORMATION
DCF-460 MDE-A
8/2014 (New)
Page 1 of 1
Instructions:
Please have the child/youth (between ages 13 and 17) read and sign this document
granting permission for release of information pertaining to substance abuse,
reproductive health and/or medical information.
Last Name Of Child:
First Name Of Child
Date Of Birth:
Link #:
I hereby give medical permission and informed consent to the following Provider/Clinic:
MDE Clinic Name & Address:
Fax #:
Please Select One
Authorization to Release Medical Information
to disclose to the Department of Children and Families any information learned from my Multi-
Disciplinary Evaluation about substance abuse (alcohol/drug use and treatment) and reproductive
health (sexual activity, sexually transmitted diseases and birth control) information.
During my evaluation, some questions may be asked about my alcohol and drug use and treatment
and reproductive health. I understand this information will be shared with DCF, including the social
workers. They will keep this personal information confidential and will not share it with anyone else
unless given permission by me or my lawyer, or unless ordered by a judge. The purpose of this
authorization/disclosure is to provide information to DCF for use in case planning.
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.
If I change my mind about this authorization, I understand it will not apply to any information already
disclosed. I also understand the information that is disclosed to DCF may be re-disclosed according
to federal law.
The signature below indicates informed consent and medical permission to conduct the MDE and the
release of medical information by the child or youth
Last Name of Child/Youth:
First Name: of Child/Youth
Signature of Child/Youth Granting Permission:
Date: