CFS 600-3 Consent for Release of Information

State of Illinois

Department of Children and Family Services

See reverse side of form for instructions

CFS 600-3

Rev 7/2015

CONSENT FOR RELEASE OF INFORMATION

1. I, , hereby give consent to:

(Provider of Information) (Address)

3. to release information concerning B.D.

4. to:

(Address)

TYPE OF INFORMATION

(CIRCLE)

5. Medical (specify):

6. Mental Health (specify):

7. Education:

8. Social History/Assessment (specify):

9. Financial (specify):

10. Other (specify):

11. THE PURPOSE FOR REQUESTING THIS INFORMATION IS:

12. Treatment, payment, enrollment, or eligibility for benefits may not be conditioned on whether or not the consent is signed by

the client or his/her personal representative. HOWEVER, I UNDERSTAND THAT IF I REFUSE TO CONSENT, THE

FOLLOWING MAY HAPPEN:

I understand that I have the right to inspect and copy the information disclosed, except for certain adoption records, certain information regarding the identity of a

source of information or the location of the minor, or under certain circumstances where information was received from a minor under a promise of

confidentiality.

I understand that I may revoke this consent at any time by notifying the Provider of Information listed in Line 2 above in writing. Revocation will be effective

except to the extent that action has been taken in reliance on this consent. I also understand that, even if I do not revoke this consent, the consent will expire one

year from the date provided on line 15 or line 16 below unless an earlier date is specified.

13. ___

Signature of Minor 12 to 17 years of age Date

14. Further, I , , the parent, or the legal guardian or

custodian, appointed pursuant to 705 ILCS 405/2-11 or 705 ILCS 405/2-27, am authorized to act on behalf of the individual minor,

, and I hereby consent to this limited

disclosure under the terms stated above. The legal guardian or custodian or parent is the legal representative of the unemancipated minor,

pursuant to HIPAA, 45 CFR 164.502(g), unless otherwise required by law.

15.

Signature of Parent, Guardian, or Authorized Agent Date Date consent expires

Address

16.

Signature of Adult Consenting to Release of Own Records Date Date consent expires

Address

17.

Signature of Witness Relationship Date

REDISCLOSURE CONSENT: The information to be disclosed is confidential and is provided only to the party specified in the above consent. The

receiving party cannot redisclose the information, with the exception of reports and other information that is required to be released to the court and

certain parties to juvenile court proceedings as authorized by the Juvenile Court Act, 705 ILCS 405. I (we) hereby consent to rediscloser to:

(if none other, enter “none other”).

Signature of Consenting Party Date Date consent expires

Signature of Minor 12 to 17 years of age Date Date consent expires

INSTRUCTIONS FOR COMPLETING THE CFS 600-3

Line 1: Enter the name of the person giving consent.

Line 2: Enter the name and address of the facility or person that is the custodian of the information requested. It may be necessary to prepare a

consent form for each provider if there are multiple providers with medical, mental health or substance abuse records that need to be

released.

Line 3: Enter the name and date of birth of the person whose records or information will be released. Prepare a separate consent form for each

person whose records are to be released.

Line 4: Enter the name and address of the agency or person to which the information will be released. Do not use specific names to avoid

problems in the event of case transfers, job changes, etc. If it will be necessary to share the information beyond DCFS, the private

agency or contractor, the Redisclosure Consent section at the bottom of the form must be completed. Without consent for redisclosure it

may be necessary to prepare additional consent forms to authorize redisclosure.

Lines 5-10: Enter the specific type of information to be released. Include relevant years of treatment/services. The law prohibits blanket consents.

The consent should cover all documents relevant to the purpose for which the information is requested. You do not need to know of the

existence of a particular document to request it. There should be a correlation between the type of information requested and the

reason(s) for the request entered on line 5. For example, if the purpose for the request is to assess parenting capabilities, the information

requested must relate to the individual’s ability to function or to parent, which may include therapist’s notes, reports or other mental

health information.

Line 11: Enter the reason for requesting the information. Frequently used reasons include:

• casework planning;

• provision of social services;

• evaluation for purposes of service planning/placement/licensing decisions;

• assessment of parenting capabilities;

• to assess progress in treatment;

• to assist in determining whether abuse or neglect occurred;

• to assess safety risks or identify risk factors that could impair the child’s safety;

• to determine prognosis for change; and

• to determine appropriate visitation.

Line 12: Enter the consequences that will be imposed by the Department if the person refuses to consent. Such consequences may include:

• Worker may attempt to screen case into court;

• Worker may seek a court order for disclosure;

• Worker may recommend to the court that the child be removed;

• Worker may be unable to recommend expanded visitation to the court;

• Visitation may be denied or delayed;

• Reunification may be denied or delayed;

• The Department will be unable to assess for provision of services;

• The Department may weigh failure to consent in determining whether the parent is compliant with services or has completed tasks

satisfactorily;

• The Department may make adverse decisions concerning foster children in your care; or

• Any other valid consequence.

Workers may not suggest or imply adverse consequences to clients beyond those that the Department can actually impose. In addition,

no adverse consequence would flow from failure to consent unless the information sought is reasonably needed by the Department in

fulfillment of legitimate departmental functions (i.e., investigating abuse or neglect allegations, providing follow-up services,

determining appropriate placement or permanency goal, supporting termination of parental rights or licensure).

Line 13: After all sections of the form have been completed, have the appropriate person sign and date the form.

• If the records are for an adult, the adult should sign on line 17.

• If the records are for a minor that is a ward, the DCFS Guardian or a DCFS Authorized Agent must sign and date the form, and enter

the address.

• Children ages 12 through 18 years of age are required to sign and date the consent in addition to their parent or legal guardian when

their mental health information and information regarding birth control services, pregnancy, treatment for sexually transmissible

diseases or drug or alcohol abuse treatment is requested.

• If a Department ward is age 18 or over and has not been declared incompetent by a court of law, only the ward may consent to release

of his/her personal information.

Line 14-15: Enter the signature, date and address of the parent, legal guardian or Authorized Agent giving consent to the person whose information is

requested. If the person is signing as a child's parent, he/she should sign Line 15 only, not Line 17. The consent will expire one year from

the date signed unless an earlier date is specified (e.g.: 60-90 days for abuse/neglect investigations; 5 to 7 months for intact family

services).

Line 16: An adult consenting to the release of his/her own records shall sign on Line 16.. When using this form to request information for an

adult's records, no information for a child should be requested on the same form. The consent will expire one year from the date signed

unless an earlier date is specified.

Line 17: A witness who is familiar with the person giving consent must sign and date the consent form when mental health information is

requested. The witness should be someone other than the worker.

Redisclosure Consent: This section must be completed when the information will be shared with persons outside of the Department or private agency

or contractor named on line 4. For information referenced in line 15 of the instructions, the same procedures must be followed for redisclosure. The

redisclosure consent will expire one year from the date signed unless an earlier date is specified.