Form KDOC-0088 "Authorization for Release of Confidential Information" - Kansas

What Is Form KDOC-0088?

This is a legal form that was released by the Kansas Department of Corrections - a government authority operating within Kansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on June 1, 2002;
  • The latest edition provided by the Kansas Department of Corrections;
  • 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 KDOC-0088 by clicking the link below or browse more documents and templates provided by the Kansas Department of Corrections.

ADVERTISEMENT
ADVERTISEMENT

Download Form KDOC-0088 "Authorization for Release of Confidential Information" - Kansas

581 times
Rate (4.5 / 5) 29 votes
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Regarding
Last Name:
First:
Middle:
Date of Birth:
Other names known by:
Social Security Number:
I (We) _
_____________________________________________________________ a
uthorize the following information to be
disclosed as indicated below.
PLACE YOUR INITIALS TO THE LEFT OF EACH ITEM APPROVED:
Information to be released from:
Information to be released to:
___
The Kansas Department of Corrections (KDOC):
___
The Kansas Department of Corrections (KDOC):
___
The Department of Children and Families (DCF):
___
The Department of Children and Families (DCF):
___
School District: USD # _______
___
School District: USD # __________
___
Medical practitioner, clinic, center or facility:
___
Medical practitioner, clinic, center or facility
_______________________________________
________________________________________
___
Mental health practitioner, clinic, center or facility:
___
Mental health practitioner, clinic, center or facility
_______________________________________
_________________________________________
___
Social Service agency or provider:
___
Social Service agency or provider:
______________________________________
_________________________________________
___
Other:
___
Other:
_______________________________________
_________________________________________
Information to be released: (PLACE YOUR INITIALS TO THE LEFT OF EACH ITEM APPROVED)
___
All information necessary to provide services
___
Academic, achievement or aptitude evaluations and recommendations
___
Social, behavioral, psychological, mental or medical histories and evaluations
___
Diagnostic and treatment progress and prognoses
___
Results of previous treatment
___
Other (specify) _________________________________________________________________________________
______________________________________________________________________________________________
The purpose or reason for the release is: (Optional. If no purpose stated, all lawful purposes are assumed)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Read before signing:
I understand that the information which I have authorized to be disclosed will be used for the purpose(s) stated. I acknowledge
that it is my responsibility to be aware of any rights of confidentiality which I may have regarding the information which I am
releasing and that by signing this consent I am waiving my rights, if any, to confidentiality for purposes which I have
approved.
If I have authorized the release of information to a person or agency providing services under contract with DCF, I have also
authorized release of the information to any person or agency providing that service under sub-contract.
This consent may be revoked in writing at any time prior to any action which has been taken in reliance upon it. This consent
expires upon (date): ______________
Signature of person (s) giving consent: ____________________________________________________ Date: ___________
____________________________________________________ Date: ___________
Relationship to person whose information is being released_____________________________________________________
State of Kansas
Kansas Department of Corrections
Forma KDOC -0088
Rev. June 2002
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
Regarding
Last Name:
First:
Middle:
Date of Birth:
Other names known by:
Social Security Number:
I (We) _
_____________________________________________________________ a
uthorize the following information to be
disclosed as indicated below.
PLACE YOUR INITIALS TO THE LEFT OF EACH ITEM APPROVED:
Information to be released from:
Information to be released to:
___
The Kansas Department of Corrections (KDOC):
___
The Kansas Department of Corrections (KDOC):
___
The Department of Children and Families (DCF):
___
The Department of Children and Families (DCF):
___
School District: USD # _______
___
School District: USD # __________
___
Medical practitioner, clinic, center or facility:
___
Medical practitioner, clinic, center or facility
_______________________________________
________________________________________
___
Mental health practitioner, clinic, center or facility:
___
Mental health practitioner, clinic, center or facility
_______________________________________
_________________________________________
___
Social Service agency or provider:
___
Social Service agency or provider:
______________________________________
_________________________________________
___
Other:
___
Other:
_______________________________________
_________________________________________
Information to be released: (PLACE YOUR INITIALS TO THE LEFT OF EACH ITEM APPROVED)
___
All information necessary to provide services
___
Academic, achievement or aptitude evaluations and recommendations
___
Social, behavioral, psychological, mental or medical histories and evaluations
___
Diagnostic and treatment progress and prognoses
___
Results of previous treatment
___
Other (specify) _________________________________________________________________________________
______________________________________________________________________________________________
The purpose or reason for the release is: (Optional. If no purpose stated, all lawful purposes are assumed)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Read before signing:
I understand that the information which I have authorized to be disclosed will be used for the purpose(s) stated. I acknowledge
that it is my responsibility to be aware of any rights of confidentiality which I may have regarding the information which I am
releasing and that by signing this consent I am waiving my rights, if any, to confidentiality for purposes which I have
approved.
If I have authorized the release of information to a person or agency providing services under contract with DCF, I have also
authorized release of the information to any person or agency providing that service under sub-contract.
This consent may be revoked in writing at any time prior to any action which has been taken in reliance upon it. This consent
expires upon (date): ______________
Signature of person (s) giving consent: ____________________________________________________ Date: ___________
____________________________________________________ Date: ___________
Relationship to person whose information is being released_____________________________________________________
State of Kansas
Kansas Department of Corrections
Forma KDOC -0088
Rev. June 2002