RECORD REQUEST FORM

• I understand that incomplete request forms will be returned and not acted upon until they are complete. 
• I understand that I will receive a copy of this form and my request will be processed within thirty (30) days, or I will be informed of the need for an extension of not more than thirty (30) additional days to process the request.
• I understand if I checked “Inspection Only,” I will need to schedule an appointment through my Care Manager to review only the information specified above.
• I understand if I checked “Copy,” I may be responsible for paying a reasonable cost-based fee for supplies, labor, copying, and/or mailing, and that the requested information will either be mailed to me via U.S. Postal Mail at the address indicated above, or I can arrange to pick up the records myself.
• I understand that my request may be denied for either of the reasons stated below. If I am denied access for either of these reasons, I understand that I may submit a written request for an administrative review of the basis for denial.
   
• If a licensed healthcare professional has determined, in the exercise of professional judgment, that the provision of access is reasonably likely to endanger the life or physical safety of any individual, or likely to cause substantial harm to the individual or another person;
• If the PHI makes reference to another person (unless the other person is a healthcare provider) and a licensed healthcare professional has determined, by exercising professional judgment, that the access request is likely to cause substantial harm to such person, or violate such person’s right to privacy.
• I understand that the following types of information are exempted from the right of access, and denial of access is not subject to appeal or review:

1. Psychotherapy notes.
2. Information compiled in reasonable anticipation of, or for use in, a civil, criminal or administrative action or proceeding.
3. Documentation that is not generated from, or identifies Ocean Partnership for Children as the creator of the document.
4. If the requested PHI is obtained from someone other than a care management organization representative or healthcare provider, under a promise of confidentiality, and it is determined that access would be likely to reveal the source of information.
5. Information is not part of the Designated Record Set (DRS).

I also understand that I have the right to file a formal complaint with either or both of the following:

• New Jersey Department of Children and Families; PO Box 717; Trenton, NJ 08625-0717
• Office for Civil Rights; U.S. Department of Health and Human Services; 26 Federal Plaza - Suite 3312 New York, NY 10278. [Voice Phone: 800-368-1019; FAX: 212-264-3039; TDD: 800- 537-7697]

Note: If you have any questions about this process, please contact our Privacy Officer, at 732-202 1585.

The mission of Ocean Partnership for Children (OPC) is to enhance the well-being of youth and their families through natural and community supports.

The confidentiality of client records is protected by federal and state laws and regulations. Release of such information is limited and requires a written release from/on behalf of the service recipient, as follows.

1. I hereby authorize Ocean Partnership for Children to RELEASE, OBTAIN and DISCUSS my health information to/from/with the following:

I/We understand that by authorizing this release, the above information may be shared, in whole or in part, to the extent necessary to develop and implement an individualized service plan. This information may become a part of a participating agency or individual’s confidential record. The New Jersey Children’s System of Care requires that all participants respect the confidential nature of the records, information and the proceedings of any meetings. Further release or use for any other purpose is prohibited and there may be penalties for any unauthorized disclosure of this information. With this release, I/We understand that this information may appear on electronic records.

I/We understand that I/We may refuse to sign this authorization and that refusal to sign will not affect the above-named youth from obtaining treatment, payment to be made, or the above-named child’s eligibility for benefits or services, however, it may affect determination of appropriate level of care. Subject to applicable law, I/We may inspect or copy any written information used/disclosed under this authorization.

I/We understand that if the person or entity that receives the information is not a healthcare provider or health plan covered by federal privacy regulations, the information described above may be re-disclosed and no longer protected by these regulations. However, the recipient may be prohibited from disclosing substance abuse information under the federal Confidentiality of Alcohol and Drug Abuse Patient Records regulations set forth at 42 CFR Part 2.

I understand that Ocean Partnership for Children is permitted under state and federal laws to charge a fee for photocopies of my records and any applicable mailing/postage fees.

I/We understand that I/We may revoke this authorization in writing at any time, except to the extent that action has been taken in reliance on this authorization. The request to revoke this authorization must be provided to in writing to the Ocean Partnership for Children’s Privacy Officer at the address listed on this form. The revocation will be effective on the date that the Privacy Officer receives the request.

I/We understand that this authorization will automatically expire upon termination of service from Ocean Partnership for Children or one (1) year from the date of the authorizing signature, whichever is sooner. I/We can receive a copy of this authorization.

(**If disclosure involves HIV/AIDS records, signature of youth age 12 or older is required; for alcohol/substance use disorder records, signature of youth is required, regardless of age)

Notice to Recipient: Participants are required to adhere to the confidentiality and release of information requirements; records are protected under applicable federal and state law and regulations, including but not limited to 42 CFR Part 2 and HIPAA.

Notice to Part 2 Recipient: This information has been disclosed to you from records protected by federal confidentiality rules (42 CFR Part 2 The federal rules prohibit you from making any further disclosure of information in this record that identifies a patient as having or having had a substance use disorder either directly, by reference to publicly available information, or through verification of such identification by another person unless further disclosure is expressly permitted by the written consent of the individual whose information is being disclosed or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of medical or other information is NOT sufficient for this purpose (See 42 CFR § 2.31The federal rules restrict any use of the information to investigate or prosecute with regard to a crime any patient with a substance use disorder, except as provided at §§ 2.12(c5) and 2.65.