UNIFORM CONSENT TO RELEASE INFORMATION
City of Alexandria
Community Services Board, Court Service Unit, Health Department
Department of Human Services, and School Division
I, / , allow / Alexandria/Arlington CASA
(Name of Consenting Person) / (Name of Referring/Initiating Agency and Staff Contact Person)
1705 Fern Street, 2nd Floor, Alexandria, VA 22302
(Agency Address and Phone Number of Contact Person)
to exchange the following information: (Check “yes” or “no” for each element)
YES / NO / YES / NO
Educational Reports / Psychological/Developmental Evaluations
Financial Information / Psychosocial, Medical, and/or Psychiatric Diagnosis
Identification of Service/ Benefit Needs / Social History
Plan for Service / Summary of Service/Benefits Rendered/Discharge Summary
Other (Please list below)
with :(Check “yes” or “no” for each agency)
YES / NO / YES / NO
AlexandriaCityPublic School Division / Alexandria Health Department
Alexandria Community Services Board/MHMRSA / Alexandria Department of Human Services
Alexandria Court Services Unit / Family Assessment and Planning Team Members
Other / State Department of MHMRSAS

For the purpose of:

Name of individual if other than consenting person:
Named Individual’s Date of Birth: / Social Security No.:
Street Address / VA / Zip code:
Consenting Person’s Relationship to Named Individual: / Self Parent Guardian / Other
This consent / INCLUDES / DOES NOT INCLUDE information placed in the named individual’s record after the date this Consent is signed.
I understand that records and other information will only be disclosed by the releasing agency to the extent necessary to assist in the purpose noted above and that subsequent disclosure by the receiving agency to other not mentioned here will not occur except as provided by law. The release expires on Or at the end of service by the receiving agency, whichever comes first. The release may be revoked by me in writing at any time and such revocation will prevent future disclosure to the extent that information has not already been released. This will stop the listed agencies from sharing this information after they know my consent has been withdrawn. However, I understand that in certain cases, such as those involving Protecting Services or the Court Services Unit, court orders or subpoenas may lead to disclosure of information not withstanding refusal, revocation, or expiration of my consent. I also understand I am not required to sign this consent to release information in order to receive service for which the named individual is otherwise eligible.
I allow the listed agencies to accept a copy of this form as a valid consent to share information. I understand that the listed agencies will keep a written record each time information is shared. This record will identify which information was shared with other agencies, when it was shared, who asked for and received information, and for what purpose. I understand that I have the right to ask the listed agencies to review this record. I do not request that the listed agencies tell me each time they share information about the named individual.
I understand that information disclosed to agencies that is protected by Federal Confidentiality of Alcohol or Drug abuse Patient Records rules (42 CFR Part 2) prohibits them from making any further disclosure of this information, unless further disclosure is expressly permitted by me, or otherwise permitted 42 CFR Part 2. Agencies receiving information cannot use any of this information to criminally investigate or prosecute the named individual.
Signature of Consenting Person: / Date:
(I f the child is capable of making a rational consent to disclose information, the consent of the minor is necessary for the disclosure of information regarding substance use or abuse.)
Other Signature: / Date:
Person Explaining Form:
Signature / Printed Name / Title Phone

NOTE: If Federal Confidentiality of Alcohol or Drug Abuse Patient Records, 42 CFR art 2 applies, complete one form per agency. Revised 10/95

CITY OF ALEXANDRIA HUMAN SERVICE PROVIDERS

Instructions for Completing the

Uniform Client Information Release Form

Revised 10/95

Make every effort to ensure that the consenting person(s) understand the provisions of the form and you should make appropriate effort to accommodate any special needs (non-English speaking, unable to read, etc.) of the consenting person(s). If you have any doubt that they are comprehending the purpose and provisions of this form, you should ask questions about the form to determine if they actually understand the purpose of the form before permitting them to sign it.

Instructions:

  1. Complete one form per person. If federal confidentiality rules for substance abuse clients apply, you must use one form per agency, otherwise one form can be used for multiple agencies.
  1. Print clearly. The only written portion should be the signatures.
  1. Print your agency's name and staff contact person's name in the space provided.
  1. Complete the information on the lines provided for the type of information and with whom. Each line (yes or no must be checked and specific entries made if the "other" lines are marked "yes".
  1. On the line provided for "Named Individual" print the name of individual whose information will be exchanged. Check the appropriate box for the authorizing person's relationship to the named individual. The authorizing person must be legally able to consent for the "Named Individual".
  1. Complete the "Named Individual's" date of birth, address, and social security number.
  1. Check whether or not the client/named individual agrees to allow information put in the records after the date the consent form is signed to be shared.
  1. On the "release expires" line you should specify a date the release expires, or a condition upon which the release expires (e.g., upon discharge). Mark through this line if the expiration of the release will be "end of services".
  1. The consenting person(s) must sign and date the release form.
  1. The staff person completing the form must sign the form, print his or her title and phone number in the "Person Explaining Form" space.
  1. If your agency requires a witness to attest the signing of the form (e.g., person can't write and can only place a mark on the form, person is not capable of understanding the form, person is a minor and needs a parent's signature, but wants to sign the form, etc.), a space is provided for this signature
  1. You must give a copy of the completed form to the consenting person(s) and keep a copy for your records.
  1. If you determine that you need to receive information in a hurry, you can call the individual service worker of the appropriate agency. You should be able to get immediate access to the requested information by faxing, and then mailing, the original release form to the agency worker. If you determine it is not urgent that you receive the information immediately, just mail the original signed release form to the worker.
  1. When sending the form to an agency, please identify the person to whom it is directed in the "Attention" line at the top of the form.

FORMULARIO UNIFORME DE AUTORIZACIÓN PARA

FACILITAR INFORMACIÓN DEL CLIENTE

Alexandria

Junta de Servicios a la Comunidad, Unidad de Servicios Judiciales, Departmento de Salud,
Departmento de Servicios Humanos y Distrito Escolar
Yo, / autorizo a
(Nombre de la persona que da la autorización) / (Nombre de la agencia iniciadora/remitente y el contacto en plantilla)
(Dirección de la agencia)
a intercambiar la siguiente información:(Marque “sí” o “no” para cada elemento)
Si / No / Si / No
Informes educacionales / Evaluaciones psicológicas/relativas al desarrollo
Información financiera / Diagnóstico psicosocial, médico y/o psiquiátrico
Identificación de las necesidades de servicios /beneficios / Historia social
Plan para la prestación de servicios / Resumen de los servicios/beneficios prestados/ Resumen de la terminación de servicios
Otro:

con:(Marque “sí” or “no” para cada agencia)

Si / No / Si / No
Escuelas Públicas de la Ciudad de Alexandria / Departmento de Salud de Alexandria
Junta de Servicios a la Comunidad de Alexandria / "MHMRSA” / Departmento de Servicios Sociales de Alexandria
Unidad de Servicios Judiciales de Alexandria / Agencias afiliadas al Equipo de Evaluación y
Planeamiento Familiar de Alexandria
Departamento de Estado de "MHMRSA"
Otra:
Con el propósito de:
en relación con
(Nombre de la persona si no es la misma que da la autorización)
Fecha de nacimiento de la persona citada / N° de Seguridad Social:
Parentesco de la persona que da la autorización con la persona citada:
Dirección: / VA / Codigo postal
La persona misma / Padre/madre / Tutor / Otro:
Esta autorización / INCLUYE / NO INCLUYE / información colocada en el expediente de la persona citada después de la fecha en que se firme esta autorización.
Entiendo que la agencia cedente sólo dará a conocer los expedientes y otra información hasta el grado necesario para contribuir al propósito citado más arriba y que la agencia receptora no la revelará posteriormente a otra agencia no citada arriba, excepto según lo disponga la ley. La autorización vence el o cuando terminen los servicios proporcionados por la agencia receptora, lo que ocurra primero. Yo puedo revocar la autorización por escrito en cualquier momento y tal revocación impedirá divulgación en lo sucesivo hasta el punto que la información no haya sido ya divulgada. Una vez que las agencias indicadas tengan conocimiento de la revocación de mi autorización, cesarán de compartir esta información. Sin embargo, entiendo que en ciertos casos, tales como los relacionados con los Servicios de Protección de Menores o la Unidad de Servicios Judiciales, las órdenes o citaciones judiciales pueden requerir la divulgación de información a pesar de la denegación, revocación o expiración de mi autorización. Asimismo, entiendo que no estoy obligado a firmar esta autorización para facilitar información a fin de recibir los servicios para los cuales la persona citada normalmente sería elegible.
Las agencias indicadas tienen mi permiso para aceptar una copia de este formulario como autorización válida para intercambiar información. Entiendo que las agencias indicadas mantendrán un registro por escrito cada vez que se comparta información. Este registro identificará la información que se compartió con otras agencias, cuando se compartió, quién solicitó y recibió la información y con qué propósito. Entiendo que tengo el derecho de pedirle el registro a las agencias indicadas para revisarlo. Las agencias indicadas no tienen que notificarme cada vez que compartan información sobre la persona citada.
Entiendo que la información facilitada a las agencias que esté protegida por las reglas sobre Confidencialidad Federal de Expedientes de Pacientes con Abuso de Alcohol o Drogas (42 CFR Parte 2) les prohibe hacer cualquier divulgación adicional de esta información, a menos que yo autorice expresamente la divulgación adicional o que de otra manera sea permitida por 42 CFR Parte 2. Las agencias que reciben la información no pueden usar ninguna parte de la misma para entablar una investigación penal o una acción judicial contra la persona citada.
Firma de la persona que da la autorización: / Fecha:
Si el menor de edad es capaz de tomar una decisión lógica respecto a la autorización para facilitar información, el consentimiento del menor de edad es necesario para divulgar información sobre el uso o abuso de sustancias.)
Otra firma: / Fecha:
Persona que explica el formulario:
Nombre en letra de imprenta Firma / Posición / Teléfono

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