Authorization Form To Use And Disclose Protected Health Information Foster Care Assessment Program (Fcap)
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1AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
FOSTER CARE ASSESSMENT PROGRAM (FCAP)
I authorize the use, disclosure and exchange of protected health information between foster parents, school personnel,
and treatment providers and the staff of the Foster Care Assessment Program, a Department of Child & Family
Services (DCFS) contractor, as provided in WA State RCW 26.44.030(7) and as outlined below.
Protected health information may be disclosed by: foster parents, school personnel, and treatment providers.
Protected health information may be disclosed to and exchanged between: social workers, treatment providers and
pediatricians of the Foster Care Assessment Program (FCAP).
Regarding: _________________________________________ Birth Date: ___/__/___
Patient/Client (Minor Child)
PURPOSE OF DISCLOSURE
The purpose of disclosure is to assist the FCAP and DCFS in planning for my children, and/or assisting in meeting the
health needs and developing a permanency plan for this child.
My Rights: I understand I do not have to sign this authorization in order to obtain health care benefits (treatment,
payment, or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization,
please read the Privacy Notice to patients posted at the facility where your information is being released. I understand
that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization
may re-disclose it, at which time it may no longer be protected under Privacy laws.
EXPIRATION OF AUTHORIZATION
This authorization expires on
(date) OR when the following event occurs: FCAP case closure
(State when you want to stop disclosing information according to this authorization). If this authorization is for the
purpose of disclosing information other than payment information to an employer or financial institution, the authorization
will be effective for no more than 90 days from the date signed or, if you specify, a period less that 90 days.
ORAL AND WRITTEN INFORMATION TO BE DISCLOSED
I SPECIFICALLY CONSENT TO THE RELEASE OF THE INFORMATION CHECKED BELOW:
PATHOLOGY SPECIMEN(S)/ SLIDE(S)
RADIOLOGY RECORDS
DISCHARGE SUMMARY
RADIOLOGY FILMS
ALL RECORDS
CONSULTATION
EEG REPORT
SUMMARY OF MEDICAL HISTORY/ TREATMENT
EKG REPORT
OPERATIVE REPORT
LABORATORY/ DIAGNOSTIC TESTS
PATHOLOGY REPORT(S)
PSYCHOLOGICAL TESTING
OTHER: __________________________________________________________________
I understand that the information in my health record may include sensitive information relating to sexually transmitted
disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). My health record may
also include sensitive information about behavioral or mental health services and treatment for alcohol and drug abuse
I understand that information related to drug/alcohol abuse evaluation and treatment is protected under the federal
regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR Part 2, and cannot be
disclosed without my written consent except as otherwise provided for in the regulations.
COURT ORDERED RELEASES OF INFORMATION
This release of information was was not court ordered; if court ordered; Case Name: __________________;
Legal Number: ____________; Date of Court Order; __/__/__; Judge/Commissioner:
I UNDERSTAND THE TERMS OF THIS AUTHORIZATION AND BY SIGNATURE AGREE TO IT.
: ____________________________
SIGNATURE
: ___/___/___
DATE
client/ patient; or parent; or legal next of kin; or
legal guardian of the client/patient.
: ____________________________
SIGNATURE
: ___/___/___
DATE
client/ patient; or parent; or legal next of kin; or
legal guardian of the client/patient.
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