Authorization for Use or Disclosure of Protected Health Information (PHI) to Caregiver/Legal Guardian
A caregiver or legal guardian may request access to youth or young adult’s Protected Health Information (PHI) by completing this form. The form will be submitted to the Quality Assurance Department at FACT for review.
Upon receipt of the completed form, a determination regarding the request will be made within the timeframes specified by the state and/or federal law. You will be notified promptly regarding the release of information being requested.