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Pa Dhs Form - Consent/release Of Information Authorization Form For The Pennsylvania Child Abuse History Certification

CHILDLINE AND ABUSE REGISTRY

P.O. BOX 8170

HARRISBURG, PENNSYLVANIA 17105-8170

CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM

FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION

I, ( _______________________________ ), hereby authorize the PA Department of Human Sevices, ChildLine to

Applicant’s Name

release my Pennsylvania Child Abuse History Clearance information directly to ( _______________________________ ).

Name of Requesting Agency

I understand that this information is confidential in nature pursuant to §6339 (relating to information in confidential reports)

of the Child Protective Services Law (CPSL) (23 Pa.C.S Chapter 63) and is not otherwise to be released by

( _______________________________ ) without my expressed authorization or pursuant to Section 3490.126 of

Name of Requesting Agency

Title 55 of the Pennsylvania Code which states this information is confidential and the requesting agency can be held

criminally liable for a breach of confidentiality related to release of this information. I also understand that the

aforementioned information will not be released directly to me ( _______________________________ ) as stated

Applicant’s Name

on the Pennsylvania Child Abuse History Certification application. I understand that I will not receive a copy

of my Pennsylvania Child Abuse History Certification directly from ChildLine; however, I may request a copy of

my Pennsylvania Child Abuse History Certification from ( _______________________________ ) upon written request.

Name of Requesting Agency

I have read this Consent/Release of Information Authorization form and fully understand and agree to its content. I further

understand and agree to all information and ramifications of the Pennsylvania Child Abuse History Certification application

as it otherwise relates to this consent. Further I understand that if I am listed in the statewide database for child abuse

that my consent allows the result stating such information to be shared with the agency/organization noted on next page.

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Pa Dhs Form - Consent/release Of Information Authorization Form For The Pennsylvania Child Abuse History Certification