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.