Fillable CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA (Pennsylvania)

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CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA (Pennsylvania)

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CHILDLINE AND ABUSE REGISTRY
P.O. BOX 8170
HARRISBURG, PENNSYLVANIA 17105-8170
CONSENT/RELEASE OF INFORMATION AUTHORIZATION FORM
FOR THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION
I, ( _______________________________ ), hereby authorize the PA Department of Human Sevices, ChildLine to
Applicant’s Name
release my Pennsylvania Child Abuse History Clearance information directly to ( _______________________________ ).
Name of Requesting Agency
I understand that this information is condential in nature pursuant to §6339 (relating to information in condential reports)
of the Child Protective Services Law (CPSL) (23 Pa.C.S Chapter 63) and is not otherwise to be released by
( _______________________________ ) without my expressed authorization or pursuant to Section 3490.126 of
Name of Requesting Agency
Title 55 of the Pennsylvania Code which states this information is condential and the requesting agency can be held
criminally liable for a breach of condentiality related to release of this information. I also understand that the
aforementioned information will not be released directly to me ( _______________________________ ) as stated
Applicant’s Name
on the Pennsylvania Child Abuse History Certication application. I understand that I will not receive a copy
of my Pennsylvania Child Abuse History Certication directly from ChildLine; however, I may request a copy of
my Pennsylvania Child Abuse History Certication from ( _______________________________ ) upon written request.
Name of Requesting Agency
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 ramications of the Pennsylvania Child Abuse History Certication application
as it otherwise relates to this consent. Further I understand that if I am listed in the statewide database for child abuse
that my consent allows the result stating such information to be shared with the agency/organization noted on next page.
Page 1 of 2
CY 999 3/16
Please send my certication result(s) to:
Agency Name:
Agency Street Address:
Agency City, State, Zip Code:
Date Applicant’s Signature
As the agency/organization representative, I understand that, except for the subject of a report,
persons who receive this information are subject to the condentiality provisions of the CPSL
and 55 Pa. Code, Chapter 3490 and are required to ensure the condentiality and security
of the information and are liable for civil and criminal penalties for releasing information
to persons who are not permitted access to this information. I agree to receive and maintain
this information in accordance with these requirements.
Date
Agency’s Representative Signature
NOTE: IF THE PENNSYLVANIA CHILD ABUSE HISTORY CERTIFICATION FORM/APPLICATION (CY 113) IS NOT COMPLETED ACCURATELY
OR IF IT IS INCOMPLETE, THE CY 113 WILL BE RETURNED TO THE APPLICANT AND NOT BACK TO A THIRD PARTY.
Revised 12-29-15
Page 2 of 2
CY 999 3/16
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CONSENTRELEASE OF INFORMATION AUTHORIZATION FORM FOR THE PENNSYLVANIA (Pennsylvania)

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Completed 20 July 2021

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