Form Cfs-100 - Differential Response Program - Authorization For Release Of Information
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1ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIFFERENTIAL RESPONSE PROGRAM
AUTHORIZATION FOR RELEASE OF INFORMATION
Client Name: __________________________________ CHRIS ID:
_________________________
Mailing Address: _______________________________ Date of Birth: _________________________
I, _____________________________________________________________________________hereby authorize
(Client or Personal Representative)
___________________________________________________ to disclose specific information about my case to:
(Name of Provider)
_________________________________________
________________________________________________
(Recipient Name)
(Recipient Address)
_________________________________________
________________________________________________
(Phone #)
(Fax #)
for the specific purpose of:
_____________________________________________________________________________
Types of Information:
(Check all that apply)
Mental Health
Financial
Social History
Education
Medical (specify): __________________________________________________________________________
Other (specify): ____________________________________________________________________________
I understand that this authorization will expire on the following date, event or condition: _____________________
____________________________________________________________________________________________
I understand that if I do not specify an expiration date or condition, this authorization is valid for up to one year,
except for disclosures for financial transactions, wherein the authorization is valid indefinitely. I also understand
that I may revoke this authorization at any time and that I will be asked to sign the Revocation Section on the
bottom of this form.
I understand that I may refuse to sign this authorization and that my refusal to sign will not affect my ability to
obtain treatment, payment for services, or my eligibility for benefits. I further understand that I may request a copy
of this signed authorization. A copy of this authorization shall be as binding as the original.
Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether or not the
consent is signed by the client or his/her personal representative. HOWEVER I UNDERSTAND THAT IF I
REFUSE TO CONSENT, THE FOLLOWING MAY HAPPEN:
____________________________________________
_________________________________
____________
____________________________________
(Signature of Client)
(Date)
(Witness-If Reguired)
______________________________________
______________
_________________________________________
(Signature of Personal Representative)
(Date)
(Personal Representative Relationship/Authority)
REVOCATION SECTION
I do hereby request that this authorization to disclose information of ________________________________
(Name of Client)
signed by ___________________________________ on _____________________________ be rescinded
(Name of Person Who Signed Authorization)
(Date of Signature)
effective _________________________ . I understand that any action taken on this authorization prior to the
(Date)
rescinded date is legal and binding.
___________________________________
______________
__________________________________
(Signature of Client)
(Date)
(Signature of Witness)
CFS-100 (10/2012)
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