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Cortland County Coordinated Children Services Initiative 60 Central Ave. Cortland, New York 13045 CSS-1003 General Release of Information Rev. 8/03 GENERAL RELEASE OF INFORMATION SECTION I - General I, residing at hereby authorize to release to; or receive from; or release to and receive from The Cortland County Coordinated Children’s Services Initiative information concerning me, and my child(ren), and I understand that this authorization covers only information required to arrange services and that Cortland County Coordinated Children’s Services Initiative will maintain confidentiality of this information. SECTION II – Protected Health Information If this Release involves Protected Health Information1, proceed with this section: 1. If this release is for the purpose of sharing protected health information, I authorize such disclosure. I understand that this authorization is voluntary. I understand that, if the person(s) or organization(s) that I authorize to receive my protected health information are not subject to federal and state health information privacy laws, subsequent disclosure by such person(s) or organization(s) may not be protected by those laws. 2. I authorize to: release to; or receive from; or release to and receive from The Cortland County Coordinated Children’s Services Initiative protected health information concerning me or my child(ren), This is being done at my request to facilitate service delivery. ---PAGE BREAK--- General Release of Information Page 2 3. I specifically authorize the disclosure of the following health information: Emergency room records Hospital/Clinic Outpatient records Laboratory & diagnostic findings Hospital Inpatient records Mental health treatment information treatment information Substance abuse treatment information Office based records Medicaid/DOH records Billing/Insurance information School records Immunization records 4. I understand that I may revoke this authorization in writing at any time by sending a signed and dated written statement to the Cortland County Department of Social Services saying that I am revoking my authorization to disclose health records, except to the extent that the person(s) and/or organization(s) named above have taken action in reliance on this authorization. SECTION III - Terms 1. This authorization expires one year from today's date, or upon the following specified event: 2. I have had the opportunity to read and consider the content of this authorization. I confirm that the contents are consistent with my direction. SECTION IV - Signatures Signed: Date: Print Name and Relationship or Authority of Personal Representative (if applicable) Witness : Date 1 Protected health information (“PHI”) is health information that is created or received by a health care provider, health plan, or health care clearinghouse which relates to: 1) the past, present, or future physical or mental health of an individual; 2) the provision of health care to an individual; or 3) the past, present, or future payment for the provision of health care to an individual. To be protected, the information must be such that it identifies the individual or provides a reasonable basis to believe that the information can identify the individual. 45 C.F.R. § 164.508.