Write the Participant's DCN in the upper right-hand corner of the room. DCN_________________
When using the form to give information to someone:
| Row: | Must include: |
|---|---|
| First Blank Line | The participant/parent/legal guardian's name |
| First set of boxes | A check in the DHSS box |
| Who received services from (dates) | The dates covered by the release. The service coordinator should assist in determining the dates, based on the purpose of the form. |
| Second set of boxes | Check the box indicating the recipient if listed. If unlisted, check the 'other' box and fill in the name of the recipient. |
| Purpose of this Disclosure | Check the only boxes that the client agrees and to that are necessary to satisfy the request. Examples include:
|
| Specific Information to be Disclosed | Check only boxes to which the client agrees and that we need to satisfy the request. |
When using the form to receive information from someone:
| Row: | Must include: |
|---|---|
| First blank line | The participant/parent/legal guardian's name. |
| First set of boxes | Check the box of the appropriate state agency. If you are requesting information from a provider, check the OTHER box and fill in the name of the provider. |
| Who received services (dates) | The dates covered by the release. The service coordinator should assist in determining the dates, bases on the purpose of the form. |
| Second set of boxes | Check the box for DHSS. |
| Purpose of this Disclosure | Check only the boxes that the client agrees to and that are necessary to satisfy the request. Examples include:
|
| Specific information to be disclosed | Check only boxes to which the client agrees and that we need to satisfy the request. |
Remember that any 'other' box can contain only one name or agency.
Several items on Page 2 of the authorization require special attention:
- Item #2 - If this line in NOT signed you CANNOT release any information that is related to drug or alcohol abuse.
- Item #4 - The parent/guardian will decide the effective date. The second line allows the authorization to expire on a given date or upon occurrence of a specific event or condition.
- Item #7 - We must inform the participant/parent/guardian that we will provide a copy of this form if they want. If they want one, copy the form and mail it or bring it on the next visit.
- We require signatures of the participant (if they have the capacity) or parent/guardian and a witness.
- The Notice of Revocation is on the form for convenience. The participant/parent/guardian completes it if they wish to revoke the authorization. They can also give you a written note revoking consent.