/
All lines must be filled in for the form to be legal.
Client’s Full Name: / DOB:
Other Names Used:
Telephone Number: / Social Security Number:
I, / authorize Saint Francis Community Services, Incorporated
509 E. Elm / (Address of office) /
Salina, KS 67401 / (City, State, Zip Code) /
785-825-0451 / (Telephone Number) /
☒ / To disclose to / Or / ☒ / To obtain from
Community Corrections / (Agency Name) /
(Provider Name if applicable) /
227 N. Santa Fe, Suite 202 / (Address) /
Salina, KS 67401 / (City, State, Zip Code) /
Confidential information from the above-named client’s treatment/health information is for the following purpose:
The information to be disclosed is:
☐ / Discharge Summary / ☐ / Social History / ☐ / Court Orders/Reports
☐ / Psychiatric Evaluation / ☐ / Progress Notes/Log Notes / ☐ / Billing Records
☐ / Medical History & Physical / ☐ / Medication Record / ☐ / Psychological Evaluation
☐ / Lab Data/Reports / ☐ / HIV/AIDS Information / ☐ / Case Plan/Treatment Plan
☐ / Special Education Records (IEP & Reports) / ☐ / Attendance Only / ☐ / Alcohol and Drug Treatment Information
☐ / School Information (transcripts and immunization) / ☐ / Foster Care Licensing & MAPP Material
☒ / Other (specify): / Any information pertaining to the placement of a child within my residence, INCLUDING CANIS, Community Corrections information, Court Records, Police Records, Employment Records, and Fingerprints. / ☐ / Diagnosis, brief description, prognosis
☒ / For treatment dates of: / Duration of investigation for purposes of placement of a child within my home. /
I understand that my treatment/health information may contain information relating to: HIV, contagious diseases, psychiatric treatment, mental health treatment, substance abuse treatment, or other conditions which may be specifically protected by law and I authorize disclosure of that information. Any alcohol and/or drug treatment records are protected under federal regulation governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I understand that once my health information has been disclosed, it will no longer be subject to federal privacy regulations and may be redisclosed by the person receiving it.
I understand that I may refuse to sign this Authorization and that my treatment or payment for my treatment will not be affected if I do not sign this form unless my treatment includes research or the reason for my treatment is to disclose information to another person.
I understand that I may see and copy the information described on this form as provided by federal regulations, and that I will get a copy of this form after I sign it.
This authorization will expire on the following date or event: / Closes after the investigation of my background either passes or fails for the purposes of placement of a child within my home. / 3
I understand that I can revoke this authorization in writing but that any revocation is not effective for disclosures that have already been made. To revoke this authorization, I should contact: Privacy Officer at 509 E. Elm, Salina, KS 67401
Signature of Client/Date / Signature of Personal Representative of Client/Date
Signature of Witness/Date / Personal Representative’s Relationship to Client
3Kansas SB 119 mandates that all authorizations are no longer valid after one year from the date of signature
Copy given to: ☐Client ☐Agency ☐File
FORMS/HIPAA/Authorization for Release of Confidential Information/August19, 2014/Page 1 of 1