Form CRR-5 Attachment D "Authorization for Release of Confidential Information - Children's Mental Health Programs" - Nevada

What Is Form CRR-5 Attachment D?

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

Form Details:

  • Released on January 20, 2015;
  • The latest edition provided by the Nevada Department of Health and Human Services;
  • 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 CRR-5 Attachment D by clicking the link below or browse more documents and templates provided by the Nevada Department of Health and Human Services.

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Download Form CRR-5 Attachment D "Authorization for Release of Confidential Information - Children's Mental Health Programs" - Nevada

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DIVISION OF CHILD AND FAMILY SERVICES (DCFS)
Children’s Mental Health Programs
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
CLIENT NAME (Print):
MEDICAL RECORD #: ______________
DATE OF BIRTH: ________________________________________
(MM/DD/YYYY Format)
Information Requested From:
Information Released To:
Each item of information to be released must be initialed
Children’s Uniform Mental Health Assessment
Discharge Summary
Medication Records
Physician’s Orders
History & Physical Exams
Targeted Case Management Assessment
Psychiatric Evaluations
Diagnosis
Strengths, Needs, & Cultural Discovery
Consultation Reports
Psychological Evaluations
Medicaid Authorization Documentation
90 Day Reviews
Care Coordination Plans
Treatment/Rehabilitative Plans
Aftercare Plan
Lab/X-ray Reports
Other (specify):
For the purpose of:
It is the policy of DCFS to release only that information about a client/patient or a former client/patient, as required by law is meets
the “minimum necessary” rule; i.e., DCFS will not release more information than is needed to satisfy the request for information.
Federal Regulations, Nevada Statutes, and/or Administrative Regulations protect medical records and any further disclosure is
prohibited without the consent of the undersigned. Executing an authorization to release confidential information in no way binds
DCFS to open its records for inspection, or to otherwise provide information which may violate the DCFS policy or applicable laws.
This authorization to release confidential information from Medical Record #_____________ is effective upon the date of execution.
This authorization is subject to written revocation at any time, except to the extent that action has already been taken in reliance
thereon. If this authorization is revoked, it will not cause a penalty or denial of services with the exception of # 2 and # 3 below. This
authorization is valid for one year from the date of execution unless revoked prior to one year.
ACKNOWLEDGEMENTS for AUTHORIZATION TO RELEASE INFORMATION
1. I understand that this authorization is voluntary and that I may refuse to sign. My refusal to sign will not affect my eligibility for
benefits or enrollment, payment for or coverage of services, or ability to obtain treatment, except as provided under # 2 and # 3 of
these acknowledgements for authorization to release information.
2. If the purpose of this authorization is for the use and/or disclosure of health information for a research study, and I refuse to sign
this authorization, DCFS reserves the right to deny treatment associated with such research.
3. If the purpose of this authorization is to disclose health information to another party based on health care that is provided solely to
obtain such information, and I refuse to sign this authorization DCFS reserves the right to deny that health care.
4. I understand that I may revoke this authorization at any time by notifying DCFS in writing, except to the extent that: (a) information
has already been released based on this signed authorization; or, (b) if authorization is obtained as a condition of obtaining
insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
5. I understand that information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal
Protected Health Information rules and regulations.
6. I understand that I may inspect and/or request a copy the information used or released by the execution of this
authorization.
7. I release DCFS and any employee of DCFS from any liability arising from my request for the release of information to the
person/agency designated above.
Legally Responsible Person (Print) OR
Legally Responsible Person Signature OR
Date
Client, at age of majority or if legally emancipated
Client Signature
(Print)
DCFS CRR-5 Limited English Proficiency (LEP) Policy
Page 1 of 1
Attachment D: Authorization for Release of Confidential Information Form
REV.: 01-20-15
DIVISION OF CHILD AND FAMILY SERVICES (DCFS)
Children’s Mental Health Programs
AUTHORIZATION FOR RELEASE OF CONFIDENTIAL INFORMATION
CLIENT NAME (Print):
MEDICAL RECORD #: ______________
DATE OF BIRTH: ________________________________________
(MM/DD/YYYY Format)
Information Requested From:
Information Released To:
Each item of information to be released must be initialed
Children’s Uniform Mental Health Assessment
Discharge Summary
Medication Records
Physician’s Orders
History & Physical Exams
Targeted Case Management Assessment
Psychiatric Evaluations
Diagnosis
Strengths, Needs, & Cultural Discovery
Consultation Reports
Psychological Evaluations
Medicaid Authorization Documentation
90 Day Reviews
Care Coordination Plans
Treatment/Rehabilitative Plans
Aftercare Plan
Lab/X-ray Reports
Other (specify):
For the purpose of:
It is the policy of DCFS to release only that information about a client/patient or a former client/patient, as required by law is meets
the “minimum necessary” rule; i.e., DCFS will not release more information than is needed to satisfy the request for information.
Federal Regulations, Nevada Statutes, and/or Administrative Regulations protect medical records and any further disclosure is
prohibited without the consent of the undersigned. Executing an authorization to release confidential information in no way binds
DCFS to open its records for inspection, or to otherwise provide information which may violate the DCFS policy or applicable laws.
This authorization to release confidential information from Medical Record #_____________ is effective upon the date of execution.
This authorization is subject to written revocation at any time, except to the extent that action has already been taken in reliance
thereon. If this authorization is revoked, it will not cause a penalty or denial of services with the exception of # 2 and # 3 below. This
authorization is valid for one year from the date of execution unless revoked prior to one year.
ACKNOWLEDGEMENTS for AUTHORIZATION TO RELEASE INFORMATION
1. I understand that this authorization is voluntary and that I may refuse to sign. My refusal to sign will not affect my eligibility for
benefits or enrollment, payment for or coverage of services, or ability to obtain treatment, except as provided under # 2 and # 3 of
these acknowledgements for authorization to release information.
2. If the purpose of this authorization is for the use and/or disclosure of health information for a research study, and I refuse to sign
this authorization, DCFS reserves the right to deny treatment associated with such research.
3. If the purpose of this authorization is to disclose health information to another party based on health care that is provided solely to
obtain such information, and I refuse to sign this authorization DCFS reserves the right to deny that health care.
4. I understand that I may revoke this authorization at any time by notifying DCFS in writing, except to the extent that: (a) information
has already been released based on this signed authorization; or, (b) if authorization is obtained as a condition of obtaining
insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.
5. I understand that information I authorize a person or entity to receive may be re-disclosed and no longer protected by federal
Protected Health Information rules and regulations.
6. I understand that I may inspect and/or request a copy the information used or released by the execution of this
authorization.
7. I release DCFS and any employee of DCFS from any liability arising from my request for the release of information to the
person/agency designated above.
Legally Responsible Person (Print) OR
Legally Responsible Person Signature OR
Date
Client, at age of majority or if legally emancipated
Client Signature
(Print)
DCFS CRR-5 Limited English Proficiency (LEP) Policy
Page 1 of 1
Attachment D: Authorization for Release of Confidential Information Form
REV.: 01-20-15
DCFS Staff Witness Name and Title (Print)
Witness Signature
Date
DCFS CRR-5 Limited English Proficiency (LEP) Policy
Page 1 of 1
Attachment D: Authorization for Release of Confidential Information Form
REV.: 01-20-15
Page of 2