Pennsylvania Child Abuse History Clearance Forms (Page 3 of 4) in pdf

Pennsylvania Child Abuse History Clearance Forms Page 3

CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM

FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CLEARANCE

(Applicant’s Name), hereby authorize the

Department of Public Welfare, ChildLine to release my Pennsylvania Child Abuse

History Clearance information directly to ________________________________

Mount Nittany Medical Center

(Name of Requesting Agency).

Human Resoures Department

1800 East Park Avenue, State College, PA 16803

I understand that this information is confidential in nature pursuant to

§6340 (relating to information in confidential reports) of the Child Protective

Services Law (CPSL) (23 Pa.C.S Chapter 63) and will not otherwise be released

by the

Mount Nittany Medical Center

(Name of Requesting Agency)

without my express authorization or pursuant to authorization by Title 55 of the

Pennsylvania Code. I understand that the aforementioned information will not be

released directly to me ______________________________ (Applicant’s Name)

as stated in the Pennsylvania Child Abuse History Clearance application.

I understand that I will not receive a copy of my Pennsylvania Child Abuse

History Clearance directly from ChildLine; however, I may request a copy of my

Pennsylvania Child Abuse History Clearance from

Mount Nittany Medical Center

_________________________________________________________

(Name of Requesting Agency) upon written request.

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 Clearance

application as it otherwise relates to this consent.

_______________

_________________________________

Date

Applicant’s Signature

(ENTER YOUR MAILING ADDRESS HERE)

Mount Nittany Medical Center

Human Resources Department

1800 East Park Avenue

State College, PA 16803

Pennsylvania Child Abuse History Clearance Forms Page 3