​Authorization For Release/Request/Exchange of Information

    Click here if you prefer to download this form. 
    YOUTH'S CONTACT INFORMATION
    I, AUTHORIZE LOGAN COUNTY FAMILY AND CHILDREN FIRST COUNCIL TO REQUEST, USE, AND/OR DISCLOSE PROTECTED HEALTH INFORMATION WITH THE FOLLOWING IN THE MANNER DESCRIBED. 
    THE INFORMATION IDENTIFIED BELOW BY MY INITIALS MAY BE TRANSMITTED BY MAIL, FAX, IN PERSON, VERBALLY, OR BY SECURE EMAIL
    ​​being the Custodial Parent, the Legal Guardian, or the Legal Representative of the Public Agency having custody of
    , born
    , a minor child, authorizes the member agencies of the COUNCIL FOR LOGAN COUNTY FAMILIES (LOGAN COUNTY FAMILY AND CHILDREN FIRST COUNCIL (FCFC)) authorized below to release, request, and exchange authorized records and information for the above named child to the COUNCIL FOR LOGAN COUNTY FAMILIES. Information provided by the COUNCIL FOR LOGAN COUNTY FAMILIES and its member agencies authorized below will be used through team discussions, assessments, and care coordination for the purpose of developing a Coordinated Plan among involved community agencies.

    §I understand that these records will be entered in an electronic health record including enrollment in an electronic billing system.

    § I further understand that these records are protected under Federal and State laws governing Confidentiality of Patient, Student, and Client Records, and cannot be disclosed or re-released without my written consent unless otherwise provided by the regulations.

    § I acknowledge that my child may be eligible and enrolled in OhioRISE and information may be exchanged with the Ohio Department of Medicaid, Aetna Better Health of Ohio, and the National Youth Advocate Program (NYAP) for that purpose.
    ​I, AUTHORIZE LOGAN COUNTY FAMILY AND CHILDREN FIRST COUNCIL TO REQUEST, USE, AND/OR DISCLOSE PROTECTED HEALTH INFORMATION WITH THE FOLLOWING IN THE MANNER DESCRIBED. 
    ​THE INFORMATION IDENTIFIED BELOW BY MY INITIALS MAY BE TRANSMITTED BY MAIL, FAX, IN PERSON, VERBALLY, OR BY SECURE EMAIL: