Form DCF-2131(F) "Authorization for the Release of Information (From Dcf)" - Connecticut

What Is Form DCF-2131(F)?

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 January 1, 2013;
  • The latest edition provided by the Connecticut State Department of Children and Families;
  • Easy to use and ready to print;
  • Available in French;
  • 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-2131(F) 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-2131(F) "Authorization for the Release of Information (From Dcf)" - Connecticut

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Department of Children and Families
AUTHORIZATION FOR THE RELEASE OF INFORMATION (FROM DCF)
DCF-2131(F)
1/13 (Rev.)
 
I,
authorize the Department of Children and Families to disclose to
(First and Last name of person granting permission)
(First and Last name, address and telephone number of person, institution or organization receiving the information)
information/records pertaining to:
(First and Last name and DOB of person who is the subject of the record)
Type of records to be released (check all that apply):
Psychiatric
Psychological
Medical
Education
Medication
Psycho-therapy notes
(NOTE: a request for psycho-therapy notes cannot be combined with a request for any other records).
Other (explain):
I specifically authorize the release of the following sensitive information from my record:
(Sign below for release of which type(s) of sensitive information you are granting)
Substance abuse (alcohol/drug)
Confidential HIV/AIDS related information
Sexually transmitted diseases
Genetic testing
Purpose of authorization/disclosure:
The nature and extent of the information to be disclosed is the entire record unless otherwise specified below:
This authorization will expire in one year, if not cancelled
Enter expiration date – one year from today
I understand that refusal to sign this authorization form will not affect my right to obtain present and future services,
except where disclosure of the records requested is necessary for services. I also understand that I may revoke this
authorization by notifying DCF or the named recipient in writing. A revocation of this authorization will not apply to any
records disclosed before the authorization is revoked. Pursuant to C.G.S. 17a-28(k) the information disclosed pursuant
to this authorization is not subject to re-disclosure by the recipient without a separate authorization for that purpose
except as provided by said statute.
Signature of person authorizing disclosure or authorized representative
Date
Check boxes below if this form has been signed by a person other than the subject of the record:
Parent/guardian
Attorney
Guardian ad litem
Other (explain):
NOTE: Confidentiality of psychiatric, drug and/or alcohol abuse and HIV/AIDS records is required and no information from
these specific records shall be transmitted to anyone else without written consent or authorization under Connecticut
General Statutes, Chapters 899c and 368x and Federal Regulations 42 CFR 2. These laws prohibit the recipient of the
record from making any further disclosure without specific written consent of the person to whom the record pertains. A
general authorization for the release of this information is NOT sufficient for this purpose.
 
Department of Children and Families
AUTHORIZATION FOR THE RELEASE OF INFORMATION (FROM DCF)
DCF-2131(F)
1/13 (Rev.)
 
I,
authorize the Department of Children and Families to disclose to
(First and Last name of person granting permission)
(First and Last name, address and telephone number of person, institution or organization receiving the information)
information/records pertaining to:
(First and Last name and DOB of person who is the subject of the record)
Type of records to be released (check all that apply):
Psychiatric
Psychological
Medical
Education
Medication
Psycho-therapy notes
(NOTE: a request for psycho-therapy notes cannot be combined with a request for any other records).
Other (explain):
I specifically authorize the release of the following sensitive information from my record:
(Sign below for release of which type(s) of sensitive information you are granting)
Substance abuse (alcohol/drug)
Confidential HIV/AIDS related information
Sexually transmitted diseases
Genetic testing
Purpose of authorization/disclosure:
The nature and extent of the information to be disclosed is the entire record unless otherwise specified below:
This authorization will expire in one year, if not cancelled
Enter expiration date – one year from today
I understand that refusal to sign this authorization form will not affect my right to obtain present and future services,
except where disclosure of the records requested is necessary for services. I also understand that I may revoke this
authorization by notifying DCF or the named recipient in writing. A revocation of this authorization will not apply to any
records disclosed before the authorization is revoked. Pursuant to C.G.S. 17a-28(k) the information disclosed pursuant
to this authorization is not subject to re-disclosure by the recipient without a separate authorization for that purpose
except as provided by said statute.
Signature of person authorizing disclosure or authorized representative
Date
Check boxes below if this form has been signed by a person other than the subject of the record:
Parent/guardian
Attorney
Guardian ad litem
Other (explain):
NOTE: Confidentiality of psychiatric, drug and/or alcohol abuse and HIV/AIDS records is required and no information from
these specific records shall be transmitted to anyone else without written consent or authorization under Connecticut
General Statutes, Chapters 899c and 368x and Federal Regulations 42 CFR 2. These laws prohibit the recipient of the
record from making any further disclosure without specific written consent of the person to whom the record pertains. A
general authorization for the release of this information is NOT sufficient for this purpose.