• Caring Partners of Morris/Sussex, Inc. 
    200 Valley Road Suite 406, Mount Arlington, NJ 07856 
    Phone: 973-770-5505 Fax: 973-770-5557
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  • Authorization to Release Health Information

    This form is to be completed by a parent/guardian or the youth (if 18 or older). Releases expire 1 year after they are signed or earlier if the family indicates. This is a dual release which allows Caring Partners to release information to the indicated person/organization and it allows for the indicated person/organization to release information to Caring Partners.
    • Caring Partners Staff Information  
    • Please choose your Care Manager's name in the drop down below and then their name will appear in the "Care Manager Name Confirmation" box. Please click the button to complete the fields below in this section. If the Care Manager's name is not listed for some reason, please choose "*Not listed or unknown". If there is an error, you can skip the rest of this section.

    • Release Information  
    •  -  - Pick a Date
    • NOTE: Youths age 14 and older are required to sign consent forms. Please ensure the youth is available to sign this form prior to submission. For youths under 18 years of age, the parent or other legally authorized person also must sign this form.

    • I authorize the following parties to release, use and disclose health information to each other as needed to coordinate care for the above youth:

      Caring Partners of Morris and Sussex, Inc.
      200 Valley Road Suite 406 Mt. Arlington, NJ 07856

      AND

      Name of Organization (if applicable):*
      Name of contact person(s) at organization:   * 
      Title/Role:   *                 



    • Expiration Date of Authorization:
      This authorization will expire on   Pick a Date   or   . If no expiration is provided, this authorization will remain in effect for one year, unless earlier revoked or terminated by the individual or individual's personal representative. You may revoke or terminate this authorization by submitting a written revocation to the Privacy Officer or other authorized representative in our office. However, no revocation or termination will be effective to the extent we have already acted in reliance on the authorization.

    • Clear
    • Clear
    •  -  -
      Pick a Date  :
    • Should be Empty: