"Authorization to Release Confidential Information Nevada Division of Child and Family Services" - Nevada

Authorization to Release Confidential Information Nevada Division of Child and Family Services is a legal document that was released by the Nevada Department of Health and Human Services - a government authority operating within Nevada.

Form Details:

  • Released on May 25, 2000;
  • The latest edition currently provided by the Nevada Department of Health and Human Services;
  • Ready to use and print;
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  • Fill out the form in our online filing application.

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AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
NEVADA DIVISION OF CHILD AND FAMILY SERVICES
CASE NAME:
I,
Guardian for
, hereby authorize
DCFS
to contact the agency, program, service provider or individual listed below for the
purpose of releasing and exchanging information concerning:
CLIENT NAME:
Date of Birth:
SSN:
AGENCY, PROGRAM OR SERVICE PROVIDER AUTHORIZED
TO RELEASE AND EXCHANGE INFORMATION
Name:
Address:
City/State/Zip:
Client must initial each item of information below to be released:
☐ Discharge Summary
☐ Nursing Notes
☐ Psychological Test Results
☐ Dates of Treatment Only
☐ Treatment Plans
☐ Psychiatric Evaluation
☐ *Communicable Disease
☐ **Educational Records
☐ Lab/X-ray Reports
☐ Physician’s Orders
☐ Criminal History Records
☐ *Alcohol Abuse
Assessment/Treatment
☐ Progress Notes
☐ Medical Diagnosis
☐ Employment Records
☐ DMV Records
☐ History and Physical Exams
☐ Intake Evaluation
☐ *Drug Abuse
☐ Legal Records
Assessment/Treatment
☐ Medication Records
☐ Psychiatric Diagnosis
☐ Diagnosis/Treatment)
☐ Other (Specify):
☐ Financial Records
☐ Consultation Reports
*If indicated by the client’s initials above, this authorization permits release of medical information under the Drug Abuse Office and
Treatment Act of 1972 (P. L. 92-255) and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act Amendments of 1974 (P. L. 93-282). Drug and alcohol abuse treatment records are further protected by Federal confidentiality
rules (42 CFR Part 2), which prohibit a person or agency from making any further disclosure of this information unless further disclosure
is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2.
Confidentiality of information regarding communicable diseases is protected under NRS 441A.220. A general authorization for the
release of medical or other information is not sufficient for these purposes. The Federal rules restrict any use of the information to
criminally investigate or prosecute any alcohol or drug abuse patient.
**The confidentiality of educational records is protected by the Family Educational Rights and Privacy Act of 1974 (34 CFR Part 99).
Under 34 CFR 303.460, the State has adopted policies and procedures that ensure the protection of any personally identifiable
information collected, used, or maintained through the Early Intervention Program, including the right of parents to written notice of and
written consent to the exchange of this information among agencies, consistent with Federal and State law. 34 CFR 300.571 further
states that an education agency or institution subject to 34 CFR Part 99 may not release information from education records to
participating agencies without parental consent, unless authorized to do so under specific provisions of 34 CFR Part 99.
This authorization constitutes a full and complete release of the agency and agency employees from any liability arising
from the release of information to the agency or person designated above. A photocopy or fax of this form is as valid as
the original. I understand that upon written request I may revoke this consent at any time, except for information that may
have already been released and/or exchanged following the signing of this form and prior to my revocation. This consent
shall expire one year after the date of my signature unless another date, event, or condition is specified below:
(Date or condition of expiration of consent - REQUIRED)
Signature of Client, Parent/Guardian or Authorized Representative
Date
Signature of Agency Representative / Program
Date
DCFS Policy 00-02 Revised 5/25/00
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION
NEVADA DIVISION OF CHILD AND FAMILY SERVICES
CASE NAME:
I,
Guardian for
, hereby authorize
DCFS
to contact the agency, program, service provider or individual listed below for the
purpose of releasing and exchanging information concerning:
CLIENT NAME:
Date of Birth:
SSN:
AGENCY, PROGRAM OR SERVICE PROVIDER AUTHORIZED
TO RELEASE AND EXCHANGE INFORMATION
Name:
Address:
City/State/Zip:
Client must initial each item of information below to be released:
☐ Discharge Summary
☐ Nursing Notes
☐ Psychological Test Results
☐ Dates of Treatment Only
☐ Treatment Plans
☐ Psychiatric Evaluation
☐ *Communicable Disease
☐ **Educational Records
☐ Lab/X-ray Reports
☐ Physician’s Orders
☐ Criminal History Records
☐ *Alcohol Abuse
Assessment/Treatment
☐ Progress Notes
☐ Medical Diagnosis
☐ Employment Records
☐ DMV Records
☐ History and Physical Exams
☐ Intake Evaluation
☐ *Drug Abuse
☐ Legal Records
Assessment/Treatment
☐ Medication Records
☐ Psychiatric Diagnosis
☐ Diagnosis/Treatment)
☐ Other (Specify):
☐ Financial Records
☐ Consultation Reports
*If indicated by the client’s initials above, this authorization permits release of medical information under the Drug Abuse Office and
Treatment Act of 1972 (P. L. 92-255) and the Comprehensive Alcohol Abuse and Alcoholism Prevention, Treatment and Rehabilitation
Act Amendments of 1974 (P. L. 93-282). Drug and alcohol abuse treatment records are further protected by Federal confidentiality
rules (42 CFR Part 2), which prohibit a person or agency from making any further disclosure of this information unless further disclosure
is expressly permitted by the written consent of the person to whom it pertains, or as otherwise permitted by 42 CFR Part 2.
Confidentiality of information regarding communicable diseases is protected under NRS 441A.220. A general authorization for the
release of medical or other information is not sufficient for these purposes. The Federal rules restrict any use of the information to
criminally investigate or prosecute any alcohol or drug abuse patient.
**The confidentiality of educational records is protected by the Family Educational Rights and Privacy Act of 1974 (34 CFR Part 99).
Under 34 CFR 303.460, the State has adopted policies and procedures that ensure the protection of any personally identifiable
information collected, used, or maintained through the Early Intervention Program, including the right of parents to written notice of and
written consent to the exchange of this information among agencies, consistent with Federal and State law. 34 CFR 300.571 further
states that an education agency or institution subject to 34 CFR Part 99 may not release information from education records to
participating agencies without parental consent, unless authorized to do so under specific provisions of 34 CFR Part 99.
This authorization constitutes a full and complete release of the agency and agency employees from any liability arising
from the release of information to the agency or person designated above. A photocopy or fax of this form is as valid as
the original. I understand that upon written request I may revoke this consent at any time, except for information that may
have already been released and/or exchanged following the signing of this form and prior to my revocation. This consent
shall expire one year after the date of my signature unless another date, event, or condition is specified below:
(Date or condition of expiration of consent - REQUIRED)
Signature of Client, Parent/Guardian or Authorized Representative
Date
Signature of Agency Representative / Program
Date
DCFS Policy 00-02 Revised 5/25/00