Contra Costa Interagency Council of Children S Services Authorization to Exchange Confidential
Contra Costa Interagency Council of Children’s Services Authorization to Exchange Confidential Information
Child’s Name:______, Date of Birth: ______
Home Address: ______, Phone: ______
The purpose of this authorization is to allow the individuals/agencies listed below, and any regular or contract employees of those agencies who are involved in my child’s case, to use, disclose, and exchange information concerning my childwith each other to develop a plan of comprehensive services. I hereby give my permission for release and exchange of confidential information limited to and as necessary to accomplish this purpose by the sources listed below.
California Children’s Services
Care Parent Network
Center for Early Intervention on Deafness
Children’s Hospital and Research Center Oakland
Contra Costa ARC
Contra Costa County Department of Social Services
Contra Costa County Office of Education
Contra Costa Health Plan
Contra Costa Mental Health Access Line
Contra Costa Public Health Nursing/Clinic Services
Contra Costa Regional Medical Center/Health Centers
Early Childhood Mental Health Program
Early Head Start/Head Start
John Muir Health
Kaiser Permanente
Lynn Center
Regional Center of the East Bay
School Districts
Special Education Local Plan Areas (SELPA)
We Care Services for Children
Other:______
I hereby authorize the agencies listed above to use and disclose the following information:
- Name and other personal identifying information
- Information related to the development of a treatment and/or service plan
- Educational records
- Summary of developmental history and progress
- Summary of medical history, diagnosis, treatment and progress
- Mental Health Information
- Prenatal History
- Court Records
I understand that I may inspect or copy the records that will be used or disclosed. I understand that my records are protected under state and federal confidentiality regulations (including Federal Regulation 42 CFR Part 2; and 45 CFS Parts 160 and 164; Civil Code 56.10 et seq., Welfare and Institutions Code sections 4514, 10850, and 5328 et seq., Education Code Section 49069) and cannot be disclosed without my written consent. Redisclosure without my specific written consent is strictly prohibited. I understand that I may revoke this consent at any time, except to the extent that action has been taken in reliance upon it. I may revoke this authorization in full or in part at any time by notifying a member of the treatment team in writing.
I understand that medical providers may not condition treatment, payment or enrollment in a health plan or eligibility for benefits based upon this authorization form.
This authorization expires automatically oneyear after my child is no longer receiving any services from any of the above agencies, or upon parent/guardian written request. A photocopy of this form is valid as the original. This authorization will be kept for six years.
I understand I have a right to receive a photocopy of this authorization form.
______ ______
PrintSignature Date
(Check one) ____Parent ___Legal Guardian ___ Authorized Representative
______
Staff Person SignatureAgency Affiliation Date
Contra Costa ICCS Authorization, 2.24.14Page 1