Form CN4401/1 "Authorization to Obtain and/Or Disclose Protected Health Information" - Connecticut

What Is Form CN4401/1?

This is a legal form that was released by the Connecticut State Department of Correction - 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 March 19, 2015;
  • The latest edition provided by the Connecticut State Department of Correction;
  • 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 CN4401/1 by clicking the link below or browse more documents and templates provided by the Connecticut State Department of Correction.

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Download Form CN4401/1 "Authorization to Obtain and/Or Disclose Protected Health Information" - Connecticut

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Authorization to Obtain and/or Disclose
CN 4401/1
Protected Health Information
REV 3/19/15
Connecticut Department of Correction
Inmate Name:
Inmate Number:
Date of Birth:
I hereby authorize the Connecticut Department of Correction (CTDOC), the Connecticut Board of Pardons and Paroles (CTBOPP), and the University of Connecticut Health
Center (UCHC) Correctional Managed Health Care (CMHC):
to OBTAIN the following information from:
Name:
(Complete name and address box)
to DISCLOSE the following information to:
Address:
(Complete name and address box)
Instructions: The person completing this authorization should be advised that this form may not be used to release psychotherapy notes. Authorizations for use or disclosure of sensitive health
information (such as HIV/AIDS or substance abuse) should be initialed by the requestor.
("X" All that apply):
I specifically authorize the release of the following information
Current Health Record
from my health record. (Initial all that apply)
(includes mental health information, other than psychotherapy notes)
Health information related to
:
Substance Abuse
(specific diagnosis, injury, operation, etc.)
(Alcohol/Drug)
Confidential HIV/AIDS Related Information
Partial Health Record - period from
to
Mental Health
(Other than psychotherapy notes)
Other health information
:
Sexually Transmitted Disease
(be specific)
I am requesting that this information be disclosed or obtained for the purpose of:
I understand that this authorization is voluntary and that I may withdraw my consent, in writing, at any time, except to the extent that it has already been acted upon. My
consent, if not withdrawn, will continue throughout my term of supervision by the CTDOC regardless of my placement and including any time spent on parole or community
supervision. If this form is used to obtain or disclose records for a person not under CTDOC supervision, consent shall be valid for a period of one (1) year from the date the
person signs, unless withdrawn.
Notice to Individual Requesting the Disclosure.
Your signature below indicates that you understand that if the organization authorized to receive the information is
not a health care provider or health plan, and the information disclosed is NOT protected by Title 42 CFR Part 2 and C.G.S. Ch. 368x, then the released information may no longer
be protected by the HIPAA Federal Privacy Regulation.
Patient Name (print)
Signature of Patient or Legal Representative
Date
Printed Name of Legal Representative *
Relationship to patient
* A copy of the personal representative's legal authority to act on behalf of the patient is attached.
Witness Signature
Date
Parent or Guardian Signature
Date
(if requestor is a minor)
If authorization is to obtain information, please provide information to address stamped below.
Name:
Facility Stamp
Authorization to Obtain and/or Disclose
CN 4401/1
Protected Health Information
REV 3/19/15
Connecticut Department of Correction
Inmate Name:
Inmate Number:
Date of Birth:
I hereby authorize the Connecticut Department of Correction (CTDOC), the Connecticut Board of Pardons and Paroles (CTBOPP), and the University of Connecticut Health
Center (UCHC) Correctional Managed Health Care (CMHC):
to OBTAIN the following information from:
Name:
(Complete name and address box)
to DISCLOSE the following information to:
Address:
(Complete name and address box)
Instructions: The person completing this authorization should be advised that this form may not be used to release psychotherapy notes. Authorizations for use or disclosure of sensitive health
information (such as HIV/AIDS or substance abuse) should be initialed by the requestor.
("X" All that apply):
I specifically authorize the release of the following information
Current Health Record
from my health record. (Initial all that apply)
(includes mental health information, other than psychotherapy notes)
Health information related to
:
Substance Abuse
(specific diagnosis, injury, operation, etc.)
(Alcohol/Drug)
Confidential HIV/AIDS Related Information
Partial Health Record - period from
to
Mental Health
(Other than psychotherapy notes)
Other health information
:
Sexually Transmitted Disease
(be specific)
I am requesting that this information be disclosed or obtained for the purpose of:
I understand that this authorization is voluntary and that I may withdraw my consent, in writing, at any time, except to the extent that it has already been acted upon. My
consent, if not withdrawn, will continue throughout my term of supervision by the CTDOC regardless of my placement and including any time spent on parole or community
supervision. If this form is used to obtain or disclose records for a person not under CTDOC supervision, consent shall be valid for a period of one (1) year from the date the
person signs, unless withdrawn.
Notice to Individual Requesting the Disclosure.
Your signature below indicates that you understand that if the organization authorized to receive the information is
not a health care provider or health plan, and the information disclosed is NOT protected by Title 42 CFR Part 2 and C.G.S. Ch. 368x, then the released information may no longer
be protected by the HIPAA Federal Privacy Regulation.
Patient Name (print)
Signature of Patient or Legal Representative
Date
Printed Name of Legal Representative *
Relationship to patient
* A copy of the personal representative's legal authority to act on behalf of the patient is attached.
Witness Signature
Date
Parent or Guardian Signature
Date
(if requestor is a minor)
If authorization is to obtain information, please provide information to address stamped below.
Name:
Facility Stamp
Authorization to Obtain and/or Disclose
CN 4401/2
Protected Health Information
REV 3/19/15
Connecticut Department of Correction
Inmate Name:
Inmate Number:
Date of Birth:
Notice to Recipients:
As the recipient of this information, you may use this information only for the stated purpose. You may disclose this information to another
party ONLY:
With written authorization from the patient of his or her legal representative;
As required or authorized by state and/or federal law; or,
If urgently needed for the patient's continued care.
If this disclosure contains information relating to HIV, behavioral health, alcohol or drug abuse education, training, treatment,
rehabilitation, or research, the following shall apply: This information has been disclosed to you from records whose confidentiality is
protected by federal law. Federal regulations (Title 42 CFR Part 2 and C.G.S. Ch. 368x) prohibit you from making any further disclosure of
it without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general
authorization for the release of medical or other information is NOT sufficient for this purpose. State law contains similar provisions with
respect to confidential HIV information, C.G.S. 19a-585.
Notice to Individual Requesting the Disclosure:
I understand that I may inspect and copy the information to be used and disclosed under this authorization and that I may receive a copy of
this signed authorization form. There may be a fee associated with the copying, not to exceed what Connecticut State law authorizes.
CTDOC, CTBOPP, UCHC/CMHC, and their employees, officers, and physicians are hereby released from any legal responsibility or liability for
disclosure of the above information to the extent indicated and authorized herein.
I understand that CTDOC, CTBOPP or UCHC/CMHC may not condition present or future treatment on the provision of this authorization.
REQUEST TO WITHDRAW AUTHORIZATION (except to the extent that the release has already been acted on)
I withdraw my consent to disclose or obtain health information authorized above.
Patient Name (print)
Signature of Patient or Legal Representative
Date
Witness Signature
Date
Parent or Guardian Signature
Date
(if requestor is a minor)
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