Caring Partners Release Form

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.
Care Manager *
Care Manager Confirmation *
Staff Email
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Extension
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Team
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Supervisor
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Sup Email
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Release Information
Youth Name *

First Name Last Name
Youth CYBER ID *
Please obtain this ID number from your Care Manager. *Please enter 99 if you do not know the number.
Youth Date of Birth *

Month Day Year
Age of Youth

Youth is under 14 yrs old or unable to sign due to developmental, physical or mental health reasons Youth is between 14 and 18 years of age Youth is 18 years of age or older Youth is over 18 but is not his/her own guardian
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 Organization (if authorizing an individual, put N/A)*
Name of contact person(s) at organization: Contact person(s) (if no one, put N/A)*
Title/Role: Title/Role (if no one, put N/A)*
Address of Organization or Individual *

Street Address

Street Address Line 2

City State

Zip Code
I hereby authorize the release, use and disclosure of the following information maintained by either of the above-named parties to the other party, and the sharing of this information between the above-named parties (Information maintained includes: Verbal Communication on progress, Personal Contact Information, Individual Service Plans, Strengths and Needs Assessment/Child Adolescent Needs and Strengths). Please Choose one:

Complete Record I will choose what items to include below
Please check any that apply: *

Verbal Communication on progress Personal Contact Information Individual Service Plans (ISPs) Strengths & Needs Assessment (SNA)/Child Adolescent Needs & Strengths (CANS)
Does the record include (check all that apply) *

Mental Health/Intellectual & Developmental Disability Records Alcohol/Drug Use Treatment Records HIV/AIDS Records
Include (indicate by initialing): Mental Health Records *
Include (indicate by initialing): Alcohol/Drug Use Treatment Records *
Include (indicate by initialing): HIV/AIDS Records *
The information will be used or disclosed for the following purpose(s) (check all that apply): *

Coordination of Individual Service Plan Benefits and Program Eligibility School Legal/Legal Proceedings
Expiration Date of Authorization:
This authorization will expire on Choose date if you wish or defined event if you wish. 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.
Expiration Date Updated
Parent/Legal Guardian Signature *

Clear
Name of person completing this authorization *

First Name Last Name
Please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
Relationship to youth *
Legal Authority *
Parent/Legal Guardian
Youth Signature, required if over 14 yrs old *

Clear
Name of youth completing this authorization *

First Name Last Name
Youth: please read attestation and check box to agree. *

I attest that I am the person named above and I signed this form. By electronically signing this form, I agree that the signature will be the electronic representation of my original wet signature and will be legally binding.
By entering my email below, I will receive a signed copy of this authorization.
example@example.com
DocDate *

Month Day Year
Date Hour Minutes AM/PM Option
DocType
Geo Stamp & Date/Time
Should be Empty:

Authorization to Release Health Information