1. READ CAREFULLY: I understand that my information and records with the Department of Social Services are confidential by law. I understand that by
signing this authorization, I am allowing the release of any and all of my information and records which I am authorized to receive as specified on this
document whether past, present or created in the future up to the expiration or revocation date of this authorization, unless otherwise authorized. The
protected information in my records may include medical treatment and/or evaluation information, mental/behavioral health information, information relating
to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), human immunodeficiency virus (HIV), other communicable or
environmental diseases and conditions, alcohol/drug abuse, application for and/or receipt of public assistance benefits, alcohol/drug abuse information,
and/or information concerning child abuse and neglect.
2. This authorization includes both information presently compiled and information to be compiled during your association or dealings with the Department
of Social Services, during the specified time frame.
3. Unless otherwise indicated, this authorization becomes effective on the date of signature below and will expire one year from that date. If you would like
to specify a different expiration date, please indicate that date here: ____________________________
4. I understand that I have a right to revoke this authorization at any time. I understand that if I revoke this authorization I must do so IN WRITING and present
my written revocation to the Privacy Officer of the Department of Social Services at 221 W. High Street, Room 230, Jefferson City, MO 65102. I further
understand that actions already taken based on this authorization, prior to revocation, will NOT be affected.
5. I understand that I have the right to receive a copy of this authorization upon request. A photographic copy of this authorization is as valid as the
original.
6. I understand that authorizing the disclosure of this information is voluntary. I can refuse to sign this authorization. I need not sign this form in order to receive
services from the Department of Social Services. I understand that I may request to inspect or request a copy of information to be used or disclosed, as
provided in 45 CFR Sections 155.260 and 164.524. I understand that any disclosure of information carries with it the potential for redisclosure by the party
receiving it and that the information may no longer be protected by law once it is in the possession of the receiving party. If I have questions about
disclosure of my information, I can contact the Privacy Officer of the Department of Social Services, my caseworker or family support eligibility specialist.
My signature below acknowledges that I have read and understood the text above, and authorize the release of my confidential information.
SIGNATURE OF CLIENT DATE
SIGNATURE OF PARENT/LEGAL GUARDIAN/REPRESENTATIVE (IF APPLICABLE)
(Please include a Description of Authority to Act on Client’s Behalf and attach a copy of the Document Granting Authority, where applicable.)
Alcohol and drug abuse treatment records are specifically protected by federal regulations (42 CFR Part 2) and by signing in the block below, I
am allowing the release of any alcohol and/or drug information or records (if any) that I may have to the agency or person specified on this form.
Prohibition of Redisclosure: Federal regulations (42 CFR Part 2) prohibit the recipient of substance abuse treatment records from making further
disclosure of those records without the specific written authorization of the person to whom those records pertain, or as otherwise specified by
such regulation. A general authorization for disclosure of medical or other information is NOT sufficient for this purpose. Sign below if you wish
to authorize the release of alcohol and drug abuse information.
SIGNATURE OF CLIENT/PARENT OR LEGAL GUARDIAN (IF APPLICABLE) DATE
NOTICE OF REVOCATION
AUTHORIZATION TO DISCLOSE SUBSTANCE ABUSE TREATMENT INFORMATION
EFFECTIVE DATE
I, _______________________________________________ , (Client) hereby revoke my authorization of this disclosure of information to the
Agency/person listed above. This revocation effectively makes null and void any permission for disclosure of information expressly given by
the above authorization. I understand that any actions based on this authorization, prior to revocation, will not be affected.
SIGNATURE OF CLIENT DATE
SIGNATURE OF PARENT/LEGAL GUARDIAN/REPRESENTATIVE (IF APPLICABLE) DATE
If you choose to revoke your authorization, please provide a copy of the completed revocation to the Privacy Officer of the Department of
Social Services at 221 W. High Street, Room 230, Jefferson City, MO 65102.
MO 886-4596 (9-18)
