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WELFARE

COMPACT

ARTICLE

6 IMPLEMENTATION

GUIDE

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Table of Contents

Alaska Tribal Child Welfare Compact

Article 6.2 Non-Financial Program Support & Operational Shared Services

Implementation Guide

Introduction

Article 6.2.1.1 With a Legitimate Interest

6.2.1.1(a) Protective Services Reports...................................................................................................... 3

6.2.1.1(b) Initial Assessment and Investigation.......................................................................................... 3

6.2.1.1(c) Access to Databases and Information......................................................................................... 4

6.2.1.1(c)(1) Online Resource for the Children of Alaska ........................................................................ 4

6.2.1.1(c)(2) Juvenile Offender Information Management Information System.......................................... 4

6.2.1.1(c)(3) Eligibility Information System or Alaska Resources for Integrated Eligibility Services .............. 5

Article 6.2.1.2 With a Court Order 5

6.2.1.2(a) Home Studies.........................................................................................................................

5

6.2.1.2(b) Licensing Files........................................................................................................................ 6

6.2.1.3 With Properly Executed Release of Information

7

6.2.1.4 Upon Request and Subject to Availability

6.2.1.4(a) Alaska Child Welfare Academy..................................................................................................

8

6.2.1.4(b) Foster Care Orientation, Training and Resources.........................................................................

8

6.2.1.5 Medicaid Eligibility

9

6.2.1.6 Social Security Benefit Eligibility Support

6.2.2 Department of Public Safety (“DPS”)

6.2.2.1 National Criminal History Record Check. AS 12.62.400...................................................................

9

6.2.2.1(a) Access to Alaska Public Safety Information Network (“APSIN”).....................................................

9

6.2.2.2 Assistance During Child Protection Investigations

10

6.2.2.3 Enforcement of Tribal Court Orders

6.2.2.3(a) Automatic Enforcement...........................................................................................................

10

6.2.2.3(b) Enforcement Upon Registration or Writ.....................................................................................

10

8

9

10

6.2.3 Department of Revenue

6.2.3.1(a) Recognition of Tribal Support Orders.........................................................................................

10

6.2.3.1(b) Enforcement of Child Support...................................................................................................

11

6.2.3.1(c) Access to State of Alaska Child Support Database........................................................................

11

6.2.3.2 Permanent Fund Dividend

11

Appendices

Appendix A – Tribal Agreement of Confidentiality (Prior to Filing a Child in Need of Aid Case)

Appendix B – Verification of Tribes to be Served for the Purpose of OCS Distributing Protective Services Reports

Appendix C – Authorization for Release of Information

Appendix D – Memorandum regarding Enforcement of Tribal Court Protective Orders

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Introduction

This guide is designed to provide information and clarification regarding the implementation of the multifaceted

subsections in Article 6 of Alaska Tribal Child Welfare Compact. This document is designed to provide updates and

guidance related to specific sub articles. Please refer to the Alaska Tribal Child Welfare Compact for additional

information.

Article 6.2.1.1

With a Legitimate Interest

6.2.1.1(a)

Protective Services Reports

Accessing PSRs

Any Federally Recognized Tribe that requests protective services reports (PSRs) regarding alleged victims who are

affiliated with their Tribe has a legitimate interest to receive that information. When there is reasonable cause to

believe that a child is a member or eligible for membership in a Federally Recognized Tribe, and the Tribe has

submitted a signed Tribal Agreement of Confidentiality (Prior to Filing a Child in Need of Aid Case – Appendix A)

and a Verification of Tribes (Appendix B), OCS will send the PSR to the designated point of contact for the Tribe

through MOVEit secure e-mail. For specific information related to setting up a MOVEit secure email account, please

contact: Alaska Tribal Child Welfare Compact Social Services Program Officer.

Confidentiality Agreements and Verification of Tribes should be submitted to: Alaska Tribal Child Welfare Compact

Social Services Program Officer.

6.2.1.1(b)

Initial Assessment and Investigation

Participating in Initial Assessments and Investigations

It is OCS’ policy to screen every report of harm to determine the race, ethnicity, and Tribal affiliation of the child and

family (CPS manual section 2.1 Protective Services Reports). If the report of abuse or neglect involves an Indian child,

OCS will make diligent efforts to identify the child’s Tribe, and notify the child’s Tribe or the local community Tribe of

the existence of the report as soon as practicable. Formal proof of membership is not necessary; informal verbal

confirmation by an authorized Tribal representative is sufficient. As stated in CPS manual section 2.2.5 Conducting

the Initial Assessment, OCS will invite the Tribe to participate in the initial assessment. Before the initial contact with

the parent or guardian the OCS Caseworker will contact the child’s Tribe, invite the Tribal representative to

participate in the initial assessment, inquire with the Tribe how OCS can be culturally appropriate during the initial

assessment, and will disclose that a protective services report was received. If a Tribal representative is not present,

the OCS Caseworker will inform the parent of their right to request one present, and right to postpone the

interview.

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6.2.1.1(c)

Access to Databases and Information

Direct access to, or information contained, in the following databases described in this section is contingent upon

the Co-Signer having a Support Services Funding Agreement to provide Services under Article 7.

6.2.1.1(c)(1)

Online Resource for the Children of Alaska (ORCA)

Non-DHSS Account Access

Co-Signer access to DHSS managed databases, specifically, ORCA, JOMIS, EIS, AIRES and APSIN, first requires a log-

on account with the State of Alaska (SOA), Department of Health and Social Service to be established. To obtain this

account, the Co-Signer must send a copy of their photo identification (ADL, State ID or Passport), a copy of the

Certificate of Completion for the SOA Health Information Protection and Accountability Act (HIPAA) training and the

Non-DHSS Employee Access Request Form to Alaska Tribal Child Welfare Compact Social Services Program Officer.

This process authorizes Co-Signers to obtain a Virtual Private Network (VPN) account that provides access to the

database(s) on a non-departmental computer. Each Co-Signer is granted a VPN; more than one Co-Signer with

DHSS access requires additional approvals and fees.

ORCA Access

Co-Signers will be provided ORCA access after a DHSS account has been approved and is in place. Co-Signers must

complete and submit an ORCA logon form and send it directly to HSS.ORCAHELP@alaska.gov. The user will be

required to maintain an active email address.

Security Requirements

Safeguarding confidential information in accordance with State and Federal guidelines requires Co-Signers to obtain

and provide on-going management of specific encryption software. The State of Alaska Security Office recommends

either Bitlocker and/or Dell Data Protection Encryption Enterprise Edition. Additionally, all operating systems should

be kept up to date (within two weeks) with the current patches and anti-virus/anti-malware software.

For additional information and support please contact:

Office of Children’s Services, Alaska Tribal Child Welfare Compact

Rodreshia Dunbar, Social Service Program Officer

Phone: 907-375-8268

Fax: 907-375-8281

Email: rodreshia.dunbar@alaska.gov

6.2.1.1(c)(2)

Juvenile Offender Management Information System (JOMIS)

Access to JOMIS is not applicable at this time.

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6.2.1.1(c)(3)

Eligibility Information System (EIS) or Alaska Resources for Integrated Eligibility

Services (ARIES)

Access to EIS and ARIES is not applicable at this time.

Article 6.2.1.2

With a Court Order

6.2.1.2(a)

Home Studies

Accessing Guardianship or Adoption Home Studies Pre Guardianship/Adoption

Co-Signers may obtain a copy of the guardianship or adoption home study before finalization of the guardianship or

adoption with an Authorization for Release of Information form from the family (Appendix C).

Email or fax a request including the name of the adoptive/guardianship parent(s) who are listed on the home study,

including the Authorization for Release of Information form to:

OCS Adoptions, State Office

Jack Eddy, Adoption Unit Program Coordinator

Phone: 907-465-3209

Fax: 907-465-2061

Email: jack.eddy@alaska.gov

Within 10 business days from receipt of the Authorization for Release of Information form, the home study will be

mailed by certified mail.

Accessing Guardianship or Adoption Home Studies Post Guardianship/Adoption

Co-Signers may obtain a copy of the guardianship or adoption home study after finalization, with a court order from

the Alaska Court System per AS 25.23.150, AS 47.10.093 and OCS confidentiality policy 6.1.2.

Email or fax a request including the name of the adoptive/guardianship parent(s) who are listed on the home study,

and the State of Alaska court order, to:

OCS Adoptions, State Office

Jack Eddy, Adoption Unit Program Coordinator

Phone: 907-465-3209

Fax: 907-465-2061

Email: jack.eddy@alaska.gov

Within 10 business days from receipt of the court order, the Adoption Unit Program Coordinator will mail the home

study by certified mail.

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6.2.1.2(b)

Licensing Files

Requesting the Non-Confidential Portion of the OCS Licensing File

Co-Signers who are engaged in licensing Tribal foster home providers may request the non-confidential portion of

the OCS licensing file by submitting a written request through email or fax, or calling the regional licensing

supervisor. OCS has 10 business days to provide the record.

Anchorage Regional Office Southcentral Regional Office

Kelly Carpenter

Julie Hubbard

Phone: 907-269-3920

Phone: 907-352-8989

Fax: 907-269-3901

Fax: 907-352-9763

Email: kelly.carpenter@alaska.gov Email: julie.hubbard@alaska.gov

or or

Snezana Ivanoksa Christine Edwards

Phone: 907-269-3966 Phone: 907-352-8941

Fax: 907-269-3901

Fax: 907-357-9763

Email: snezana.ivanoska@alaska.gov Email: christine.edwards@alaska.gov

Northern Regional Office Western Regional Office

Carmen Brooks Joanna Williams

Phone: 907-451-2094 Phone: 907-303-5125

Fax: 907-451-2814 Fax: 907-543-4431

Email: carmen.brooks@alaska.gov Email: joanna.williams@alaska.gov

Southeast Regional Office

Alana Medel

Phone: 907-465-2946

Fax: 907-465-1669

Email: alana.medel@alaska.gov

The non-confidential portion of the licensing file includes:

• Activity Notes: names of children in care are not disclosed

.

• C

orrespondence: any written communication between the licensing worker, the applicant/licensee,a

nd

o

thers involved in the regulatory proce

ss.

• L

icense: a copy of the signed foster home or child placement agency license, approved/denied barrier crim

e

v

ariance notice, approved/denied general variance notice, and change summaries

.

• Non-Confidential Licensing Documentation: training documentation, completed investigation/inspection

f

inal reports and any enforcement actions, Warning Notice and allegation of compliance or writte

n

r

esponses to the reports, and licensing documentation which includes, plan of care, and familycharacteristic

s

c

hecklist

.

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Requesting Confidential Portion of OCS Licensing File (Sections V and VI)

Co-Signers who are engaged in licensing Tribal foster home providers may request the confidential portion of the

OCS licensing file by submitting a Release of Information or court order from the Alaska Court System, through

email or fax, or calling the regional licensing supervisor. See below as to what confidential records can be release

with a signed Release of Information and what records require a court order. OCS has 10 business days to provide

the record.

The confidential portion of the OCS licensing file that requires a release of information form to access includes:

• background check clearance forms, state fingerprint results, BCP on-line application confirmation page

,

c

ertification of medical condition regarding fingerprints, denied barrier crime variance notices, financi

al

summary, medical information release, and employees in the foster home, notices of license denial, requests

for hearing, assessments or evaluations, Foster Care Standard-by-Standard evaluation and Narratives, annual

se

lf-monitoring reports, evacuation plan, requests for sanitation and fire inspections, and Review Informatio

n

F

oster Parent form, reassessment of foster family, barrier crime variance application packet; health histor

y

and

medical or mental health information about the person providing conse

nt.

• A

pplications: these documents contain personal information that is protected by the Personal Informatio

n

P

rotection Act. Social security numbers, driver’s license numbers, or personal information used toestabli

sh

c

redit may be deleted prior to disclosure

.

The confidential portion of the OCS licensing file that requires a court order to access includes:

• Pending Reports of Inspection, pending Reports of Investigation, investigation notes, ORCA activity notes

or

c

orrespondence about children in care; federal fingerprint result

s.

R

equesting Open Investigations of Current and Prospective Foster Parents

Open investigations on current and prospective foster parents shall be disclosed to Tribes/Tribal Organizations who

are involved in licensing the home that has the open investigation. Submit the request for information with a signed

Release of Information to the regional licensing supervisor.

Article 6.2.1.3

With a Properly Executed Release of Information

To the full extent permitted by federal and state law, OCS shall provide, upon receipt of a properly executed release

of information to the Co-Signer, the information authorized for disclosure, including all of the information in the

background check regarding family members, foster care or other providers, and potential providers.

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Article 6.2.1.4

Upon Request and Subject to Availability

6.2.1.4 (a)

Alaska Child Welfare Academy

Co-Signers may send employees and volunteers to the Alaska Child Welfare Academy subject to available space. No

fee shall be required for attending the Academy, as funding allows. However, travel expenses shall be the sole

responsibility of the Co-Signer.

UAA Alaska Child Welfare Academy

Lisa Tanga

Phone: 907-786-6743

Fax: 907-786-6735

Email: lktanga@alaska.edu

6.2.1.4 (b)

Foster Care Orientation, Training, and Resources

OCS shall make foster care orientation, training and resources available to Tribally licensed foster care providers or

applicants to the same extent as they are available to state foster care providers or applicants. Alaska Center for

Resource Families will provide foster care orientation, training, and resources to Co-Signer Tribally licensed foster

care providers.

Northern Region:

• Fairbanks: 907-479-7307 or toll free in Alaska1-800-478-7307

S

outheast Region:

• Rural Outreach Coordinato

r

F

airbanks: 907-479-7307 or toll free in Alaska 1-800-478-

7307

S

outhcentral Region:

• Mat-Su: 907-376-4678 or toll free in Alaska 1-866-478-

7307

A

nchorage and Western Regions:

• Anchorage: 907-279-1799 or toll free in Alaska1-866-478-7307

Alaska Center for Resource Families -Information and Online Resources:

• Website: www.acrf.or

g

• F

oster Care Orientation: https://www.acrf.org/foster-steps.php?tn=

3

• T

raining Calendars: https://www.acrf.org/training.php?tn=

6

• S

elf-Study and Online Training: https://www.acrf.org/resources-self-study.php?tn=

5

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Article 6.2.1.5

Medicaid Eligibility

Co-Signers who have a Tribal/State Title IV-E Pass-Through Maintenance Agreement or a Tribal Direct IV-E

Agreement, the Office of Children’s services will process Medicaid eligibility if the child is Title IV-E eligible. Tribes

with Direct Funded Agreements must provide documentation illustrating that the child is Title IV-E eligible to OCS

at hssocslegal@alaska.gov

To access Medicaid eligibility for children that are not deemed Title IV-E eligible, an application GEN 50C must be

completed and submitted to the Department of Public Assistance. The application can be found at

http://dpaweb.hss.state.ak.us/e-forms/pdf/Gen50c.pdf

Article 6.2.1.6

Social Security Benefit Eligibility Support

Co-Signers who would like to receive technical assistance when applying for social security benefits for a child in

custody of a Tribe, please contact:

Office of Children’s Services, Alaska Tribal Child Welfare Compact

Rodreshia Dunbar, Social Service Program Officer

Phone: 907-375-8268

Fax: 907-375-8281

Email: rodreshia.dunbar@alaska.gov

Article 6.2.2

Department of Public Safety ("DPS")

6.2.2.1

National Criminal History Record Check. AS 12.62.400

Criminal history checks will be conducted by OCS Caseworker or the Tribal Child Welfare Compact Social Service

Program Officer prior to referrals of services that necessitate background checks before they are conducted.

6.2.2.1 (a)

Access to Alaska Public Safety Information Network

A letter has been drafted for Commissioner Davidson to send to Commissioner Monegan to amend the current

APSIN Agreement to implement the terms and conditions of the Compact. OCS will conduct background checks

until Co-Signers are granted access to APSIN.

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Article 6.2.2.2

Assistance During Child Protection Investigations

As stated in the Compact:

Uponreceipt of a signed writ of assistance from the Alaska State Court, the Alaska State

Troopers shall accompany tribal staff conducting tribal child protection investigations. To the extent DPS is

permittedtocharge OCSfor this assistance,itmay require therequestingCo-Signer to pay equivalentfees.

Article 6.2.2.3

Enforcement of Tribal Court Orders

Please see Appendix D – Memorandum regarding Enforcement of Tribal Court Protective Orders issued by Deputy

Attorney General Robert E. Henderson of the State of Alaska Criminal Division on July 31, 2017. “All protective

orders issued by an Alaska Court, a court of another state or territory, a U.S. military tribunal, or Tribal court

shall

be

enforced as if it was issued by an Alaska court.”

• The filing of a Tribal Order with the Alaska court is not necessary

• An order need not be entered into APSIN or NCIC

6.2.2.3(a)

Automatic Enforcement

As stated in the Compact:

DPS shall enforce protection/protectiveorders issuedby tribalcourts, providedthe order

identifies the petitioner and respondent; containsprovisions intendingtoprevent violent or threatening acts,

harassment,sexualviolence,contact,communication,proximitytoaperson,orstalking;andappearsauthenticonits

face.

See Appendix D for supporting information.

6.2.2.3(b)

Enforcement Upon Registration or Writ

As stated in the Compact:

Upon receipt of a writfroma state court, the StateTroopers shall enforceany tribal court

order, including those identified in Section6.2.2.3(a).

Article 6.2.3

Department of Revenue

6.2.3.1(a)

Recognition of Tribal Support Orders

As stated in the Compact:

The Alaska Child Support Services Division (CSSD) recognizes tribal child support orders

just like child supportorders issued by another state.

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6.2.3.1(b)

Enforcement of Child Support

As stated in the Compact:

Upon application and receipt of required documentation, CSSD will enforce child support

for a child in Tribal custody, or if no order exists, CSSD will take steps to establish an order for a child in tribal

custody.

6.2.3.1(c)

Access to State of Alaska Child Support Database

Access to CSSD’s case management system will be limited to information currently provided to Health and Social

Services (HSS) and must be for business related eligibility purposes only. HSS will serve as the first point of contact,

and will use their limited access to provide the information to the requesting Co-Signer. If more information is

needed, HSS will forward the request to CSSD’s designated point of contact.

Child Support Services Division, Tribal Child Support

Jared Hakkinen

Phone: 907-269-6922

Email: jared.hakkinen@alaska.gov

Article 6.2.3.2

Permanent Fund Dividend

Co-Signers can opt to place PFD funding for children in Tribal custody into the State Trust Fund, to do so:

• Co-Signers will need to complete the PFD application for children in Tribal Custody “T-A

pp”

o P

FD is considering updating the T-App to include the following option

s:

 Di

rect Deposit into Tribally identified accoun

t;

 Di

rect Deposition into DHSS account - this will deposit the funds into the state trus

t;

 P

aper Check (Tribe can deposit in own account/trust; however can also use the PFDtrust

)

• F

unds placed into the trust as a result of the T-App will be released upon tribal court ord

er

• F

unds placed into the trust as a result of DHSS application will be released pursuant to state statute. Thes

e

f

unds cannot be transferred to the Tribe (even upon a jurisdiction transfer) without Alaska State courtorder

.

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APPENDIX A

TRIBAL AGREEMENT OF CONFIDENTIALITY

(PRIOR TO FILING A CHILD IN NEED OF AID CASE)

Prior to filing a Child-in-Need-of-Aid (“CINA”) case in state court, the Office of Children’s Services

(“OCS”) may provide information to Alaska tribes regarding child protection investigations that involve

their tribal children. This information sharing may occur for any of the following reasons: so that a Tribe

may work collaboratively with OCS to investigate allegations of child abuse and neglect; so that a Tribe

can aid in providing services or placing a child if releasing the information is in the child’s best interest; or

a Tribe has requested the information from OCS and indicates the request is for a purpose related to child

protection, including investigating the allegations in the Protective Services Reports (“PSR”). In addition

to the PSR, information sharing at this stage may include reports of harm, ORCA notes, safety plans,

police reports, and other investigative reports.

The information that is provided by the OCS to a Tribe is sensitive and confidential. Maintaining

the confidentiality of this information is vital to protecting both the safety of the children and the

privacy of the family. The information provided by the OCS to the Tribe must therefore not be disclosed

to any person or entity except that information which is necessary to carry out the investigation process,

initiate a tribal child protection proceeding, and/or provide immediate assistance and intervention

services to the family.

By signing below, the Tribe acknowledges that it has reviewed, understood and agrees to keep

child protection information confidential as set forth above. The Tribe also confirms that it has a written

policy regarding protection of confidential information, and that tribal representatives receiving

confidential information have received a copy of the policy.

Signature of Authorized Tribal Representative Date

Name (print):

Title:

Name of Tribe:

GOVERNOR

BILL

WALKER

APPENDIX B

Department of

Health and Social Services

OFFICE OF CHILDREN’S SERVICES

Director’s Office

P.O. Box 110630

Juneau, Alaska 99811-0630

Main: 907.465.3170

Fax: 907.465.3397

PRINT NAME OF TRIBE/TRIBAL ORGANIZATION HERE

Verification of Tribes to be Served for the Purpose of OCS Distributing Protective Services

Reports

List of Tribes (if applicable):

Tribe / Tribal Organization Point of Contact:

Name

Phone Number

Email Address to receive PSRs through MOVEit

I certify that the above-listed Tribes will be served by our Tribe / Tribal Organization for

purposes of OCS distributing Protective Services Reports. I will inform the OCS point of

contact of any changes to the above list as soon as they are known.

Tribe / Tribal Organization Representative or Designee (signature & printed)

Date

APPENDIX C

□

□ □

Alaska Department of Health and Social Services

Office of Children’s Services

AUTHORIZATION FOR RELEASE OF INFORMATION

Name:

SSN: _ Record # or Other ID: _ Date of Birth: _

Other Names Under Which Records Might Be Filed:

Person/Organization Releasing Information:

Person/Organization Receiving Information: (include address if needed)

Description of information to be released: (If substance abuse information is to be released from a federally assisted substance

abuse treatment center, then this information must be included in the description)

Case Plan Safety Plan Visitation Plan Initial Assessments

Adoption Homestudy Guardianship Homestudy

Court Documents (please specify):

Other (please specify):

The purpose of the release of this information is:

I hereby authorize the use or disclosure of my health care and/or other information as described above. I understand that this

authorization is voluntary. I understand that my records may contain sensitive information. I understand that I may revoke this

authorization at any time by notifying the individual(s) or organization releasing this information in writing, but if I do, it won’t have

any affect on actions taken on this authorization before my revocation was received. I understand that the individual(s) or

organization releasing this information will not condition my treatment, payment, enrollment in a health plan (if applicable) or

eligibility for benefits on whether I provide this authorization. I understand that if the person(s) or organization authorized to receive

this information is not a health plan or health care provider, the released information may no longer be protected by federal privacy

regulations. To the extent that this information is required to remain confidential by federal or state law, the recipient of this

information must continue to keep this information confidential. I understand that I may request a copy of this signed authorization.

This authorization expires on the following date or event:

Signature of Client or Personal Representative

(Or Witness if signature is by mark)

Date

Printed Name of Personal Representative or Witness Description of Personal Representative’s Authority

NOTE: This authorization was revoked on:

Date

_ (see attached revocation)

RECIPIENT INFORMATION: If the identifying information released pertains to the diagnosis, treatment, or referral for treatment for a

substance abuse disorder, the confidentiality of the information is protected by federal law (42 CFR Part 2) prohibiting you from making any

further disclosure of this information without the specific written authorization of the person to whom it pertains or as otherwise permitted by 42

CFR Part 2. A general authorization for the release of medical or other information if held by another party is NOT sufficient for this purpose.

The federal rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient.

06-5870 (Rev. 11/2017) A PHOTOCOPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL Page 1 of 2

HIPAA Compliant

APPENDIX D

STATE OF ALASKA

Department of Law

MEMORANDUM

Criminal Division

TO: All Alaska Law Enforcement

FROM: Robert E. Henderson

Deputy Attorney General, Criminal Division

DATE: July 31, 2017

SUBJECT: Enforcement of Tribal Court Protective Orders

All protective orders issued by an Alaska court, a court of another state or territory, a U.S. military tribunal, or

tribal court shall be enforced as if it was issued by an Alaska court. AS 18.66.140; 18 U.S.C. § 2265.



The filing of an order with an Alaska court is not necessary.



An order need not be entered into APSIN or NCIC.



Required Order Elements:

• An order must identify the petitioner and respondent.

• An order must contain provisions intending to prevent violent or threatening acts, harassment, sexual

violence, contact, communication, proximity to a person, or stalking.

• An order must appear authentic. Law enforcement officers are not to investigate beyond looking at the

order itself. Any jurisdictional or due process issues will be addressed by the prosecutor and/or an

Alaska court.



Charging Crime of Violating Protective Order: In order to charge the Alaska crime of violating a protective

order contrary to AS 11.56.740, the order must contain provisions that are similar to provisions found in

AS 18.66.100(c)(1)-(7) or AS 18.65.850(c)(1)-(3) (the language need not be identical).



Child Custody Orders. When violations of child custody orders are not criminal offenses, order provisions

nevertheless are to be enforced provided the provisions relate to protecting a victim of domestic violence,

sexual assault, dating violence, or stalking.



Stand by Orders. Stand by orders are to be followed provided the order provisions relate to protecting a

victim of domestic violence, sexual assault, dating violence, or stalking.



Mandatory and Warrantless Arrests. Alaska mandatory and warrantless arrest law provisions are to be

followed in connection with enforcement of all protective orders.

Alaska Department of Health and Social Services

Office of Children’s Services

INSTRUCTIONS:

The elements of this form described below (1-5) and marked with an asterisk (*) MUST BE COMPLETED. There are NO exceptions.

Incomplete authorization forms are invalid and WILL NOT BE PROCESSED!

1.

Client Information *: Enter the Name, SSN, Case # or Client ID, and Date of Birth (if known) of the individual whose information (PHI) is

being released or requested. At least one identifier other than name must be present – e.g. SSN or DOB or Case # or ClientID

2.

Organization Releasing and Receiving Information *: Enter “DHSS” and/or “Division Name” or “Program Name” ONLY on either the

Releasing line or Receiving line depending on whether the Department or Division is receiving information or releasing information. DO NOT

enter specific DHSS employee names! The client or client’s representative should indicate a specific name (and address, if known) of the

individual(s) or organization(s) receiving or releasing the information. Multiple individuals/organizations may be specified on a single

authorization if they are ALL receiving the same information and are clearly specified. Use additional authorizations if individuals/organizations

are receiving different information or if there is not enough room on a single authorization to clearly specify multiple individuals/organizations

on the Receiving Information lines.

3.

Description of Information to be Released *: A specific description of the information that is being requested or released should be indicated.

Detail is not required, but is preferred. For example, “Medical and mental health records” rather than “All information you have”. If alcohol or

other substance abuse information is being released or requested, this must be explicitly stated in the description. For example, “Medical and

mental health records, including alcohol or substance abuse records”.

4.

Expiration Date/Event *: Enter a date or event that is reasonable and acceptable to the client or client’s representative. For instance, “One year

from the date of this authorization” is generally accepted as a reasonable expiration date.

5.

Signatures & Dates *: The individual whose PHI is being released or requested should sign and date the form. If the individual is a minor, or is

otherwise not able to sign the form, the individual’s authorized representative or witness should sign and date it. If an authorized representative is

signing the form on behalf of the client, the representative’s “legal authority” to act on the part of the individual must be verified first and then

described in the appropriate space. Legal authority includes but is not limited to a parent who signs the form for a minor child or an individual

who has power of attorney over the affairs of the individual whose PHI is being released or requested.

6.

Revocation Date: The revocation date on the reverse side of this form does NOT need to be completed UNLESS the individual has revoked this

authorization using form 06-5872 Revocation of Authorization. If revoked, a copy of the revocation should be attached to this form & the date of

revocation noted of the front of this form.

7.

ALL authorization forms MUST be retained for SIX (6) YEARS from the date of signature. This form should be stored in the client file, if

one is maintained. Some programs have procedures requiring the form, or a copy of the form be retained solely or additionally by the Division

Privacy Official. Please refer to the appropriate Division or Program specific procedures or inquire with your Division Privacy Official regarding

any additional retention requirements of authorization forms.

8.

If requested, provide a copy of this authorization to the client or client’srepresentative.

QUESTIONS?

Contact the Office of Children’s Services Privacy Official at (907) 465-2105 or the DHSS Privacy Official at (907) 465-2150 with any concerns you

may have.

FOR DHSS & BUSINESS ASSOCIATE USE ONLY

Use this section to document ALL disclosures made by DHSS or business associates based on this authorization. Please supply the information

below detailing information about the disclosures that may not be adequately described the front of this authorization. For instance, if

Description of Information To Be Released on the front states “All information you have on me” – then completely describe the data that was

actually disclosed, such as “Medicaid eligibility and disability information from 1993 - 2001” or “Immunization data from 2001

- 2003”. Indicate the actual date(s) of disclosure(s) and the name and division of the employee(s) releasing the data. Attach additional

documentation if necessary.

Disclosure Date Disclosed By (Name/Division) Detailed Description of Information Disclosed

_

06-5870 (Rev. 11/2017) A PHOTOCOPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL Page 2 of 2

HIPAA Compliant

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