Form CN 4402 Authorization for Release of Non-health Information - Connecticut

Form CN4402 is a Connecticut State Department of Correction form also known as the "Authorization For Release Of Non-health Information". The latest edition of the form was released in June 30, 2009 and is available for digital filing.

Download an up-to-date Form CN4402 in PDF-format down below or look it up on the Connecticut State Department of Correction Forms website.

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Authorization for Release of Non-Health Information
CN 4402
REV 6/30/09
Connecticut Department of Correction
Inmate name:
Inmate number:
Date of birth:
I hereby authorize the State of Connecticut, Department of Correction and its staff at the (list facility):
To disclose the following information from my master file:
(initial)
Date(s) of admission/discharge.
(initial)
Other master file information (specify):
(initial)
To disclose the following information (specify):
(initial)
Individual/organization to receive information:
The specific purpose of this request:
I understand that this authorization is voluntary and that I may withdraw my consent at any time prior to the release
of the indicated information. My consent, if not withdrawn, will continue throughout my term of supervision by the
DOC regardless of my placement and including any time spent on parole or community supervision.
Return to (facility stamp) :
requestor signature
date
witness signature
date
parent/guardian signature
date
(if requestor is a minor)
Authorization for Release of Non-Health Information
CN 4402
REV 6/30/09
Connecticut Department of Correction
Inmate name:
Inmate number:
Date of birth:
I hereby authorize the State of Connecticut, Department of Correction and its staff at the (list facility):
To disclose the following information from my master file:
(initial)
Date(s) of admission/discharge.
(initial)
Other master file information (specify):
(initial)
To disclose the following information (specify):
(initial)
Individual/organization to receive information:
The specific purpose of this request:
I understand that this authorization is voluntary and that I may withdraw my consent at any time prior to the release
of the indicated information. My consent, if not withdrawn, will continue throughout my term of supervision by the
DOC regardless of my placement and including any time spent on parole or community supervision.
Return to (facility stamp) :
requestor signature
date
witness signature
date
parent/guardian signature
date
(if requestor is a minor)

Download Form CN 4402 Authorization for Release of Non-health Information - Connecticut

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