FACT PHI Release to Caregiver/LG

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.

Individual Child's Name*

First & Last Name

Requestor's Name, if parent or guardian*

First & Last Name

Individual Child's Date of Birth*

Date

Child's Social Security Number*

Format: 123-12-1234

IF YOU ARE REQUESTING A COPY OF THE PHI ITEMS BE MAILED TO YOU, KINDLY PROVIDE AN ADDRESS. Please note that you may be charged a fee for copying or summarizing and mailing the information.

Street Address

City

State

Zip Code

Please indicate below what part of the record you are requesting*

Evaluations specify:

Evaluations specify*

(For amending DRS only) Please indicate the part of the record you wish to amend and explain the desired information to be amended:

Please indicate with a check mark the format in which you wish to have access*

_Paper Copy_Summary_Email

All-access and amending is an in-person inspection. You will be telephoned to set up a time that is convenient for you to meet and review the DRS. Please provide a telephone number where you can be reached.

Telephone*

Signature of Parent/Legal Guardian*

Signature of Youth (if 14 years of age or older)

Please feel free to contact Richard Thompson at 908-789-8500 ext. 155 with any questions or comments.