Form DCF-2112 "Confidentiality Agreement" - Connecticut

What Is Form DCF-2112?

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 June 1, 2017;
  • 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 printable version of Form DCF-2112 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-2112 "Confidentiality Agreement" - Connecticut

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DCF-2112
06/2017(Rev.)
State of Connecticut
Department of Children and Families
CONFIDENTIALITY AGREEMENT
Connecticut General Statutes §17a-28(b) states:
"… records maintained by [DCF] shall be confidential and shall not be disclosed… Any
unauthorized disclosure shall be punishable by a fine of not more than one thousand dollars
or imprisonment for not more than one year, or both."
Connecticut General Statutes §17a-101k states:
"...The information contained in the [Central R]egistry and any other information relative to
child abuse, wherever located, shall be confidential…"
"...Any violation of this section or the regulations adopted by the commissioner under this
section shall be punishable by a fine of not more than one thousand dollars or imprisonment
for not more than one year."
The Health Insurance Portability and Accountability Act of 1996 (August 21), Public Law
104-91 requires:
"HIPAA seeks to safeguard the privacy and security of health information (oral, written or
recorded in any form) that relates to either the physical or mental health or condition of an
individual, the provision of health care to an individual, or the payment for health care
provided to an individual..."
"As a business associate, the licensed family resource must comply with all terms and
conditions of the HIPAA provisions."
In accordance with the above statutes, I agree that I will not disclose confidential
information, including health information, about children in the care of DCF and their
families which may come to my attention to anyone other than DCF staff unless
authorized in writing to do so.
I acknowledge that I have received a copy of this Confidentiality Agreement and the
HIPAA provisions.
Name (Please print)
Signature
Date
Witness (Please print)
Signature
Date
Each member of the household age 18 years and older
must sign a separate Confidentiality Agreement.
DCF-2112
06/2017(Rev.)
State of Connecticut
Department of Children and Families
CONFIDENTIALITY AGREEMENT
Connecticut General Statutes §17a-28(b) states:
"… records maintained by [DCF] shall be confidential and shall not be disclosed… Any
unauthorized disclosure shall be punishable by a fine of not more than one thousand dollars
or imprisonment for not more than one year, or both."
Connecticut General Statutes §17a-101k states:
"...The information contained in the [Central R]egistry and any other information relative to
child abuse, wherever located, shall be confidential…"
"...Any violation of this section or the regulations adopted by the commissioner under this
section shall be punishable by a fine of not more than one thousand dollars or imprisonment
for not more than one year."
The Health Insurance Portability and Accountability Act of 1996 (August 21), Public Law
104-91 requires:
"HIPAA seeks to safeguard the privacy and security of health information (oral, written or
recorded in any form) that relates to either the physical or mental health or condition of an
individual, the provision of health care to an individual, or the payment for health care
provided to an individual..."
"As a business associate, the licensed family resource must comply with all terms and
conditions of the HIPAA provisions."
In accordance with the above statutes, I agree that I will not disclose confidential
information, including health information, about children in the care of DCF and their
families which may come to my attention to anyone other than DCF staff unless
authorized in writing to do so.
I acknowledge that I have received a copy of this Confidentiality Agreement and the
HIPAA provisions.
Name (Please print)
Signature
Date
Witness (Please print)
Signature
Date
Each member of the household age 18 years and older
must sign a separate Confidentiality Agreement.