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NJ DCF Logo with reverse copy 

 

New Jersey Department of Children and Families Policy Manual

 

Manual:

CP&P

Child Protection and Permanency

Effective Date: 12/16/13

Volume:

X

Forms

Chapter:

A

Forms

Revised

Date: 2/19/19

Subchapter:

1

Forms

Issuance:

11.48

CP&P Form 11-48, Consent for the Release of Confidential Substance Use Disorder Treatment Information to the Division of Child Protection and Permanency

 

 

Click here to view or print a blank CP&P Form 11-48, Consent for the Release of Confidential Substance Use Disorder Treatment Information to the Division of Child Protection and Permanency.

 

Click here to print or view this form in Spanish, 11-48(S)

 

WHEN TO USE IT

 

Use CP&P Form 11-48 to obtain written consent for outside substance use disorder (SUD) treatment providers to release SUD treatment records of adult and minor clients to CP&P. This form should also be used to obtain written authorization for CP&P to re-disclose substance use disorder treatment records to other outside entities on a case-by-case basis (i.e. therapists, psychologists, clinicians, etc.).

 

HOW TO USE IT

 

When seeking to obtain substance use disorder treatment records, the assigned Worker/CP&P representative is responsible for obtaining written consent from the client and delivering the signed consent form to the substance use disorder treatment provider in possession of the records. Signatures must be obtained from both adult and minor clients. A minor client does not require the signature of an adult for the consent to be valid. 

 

The assigned Worker shall ensure that the client is informed of his or her right to restrict the use and/or type of information authorized for release, and of his or her right to revoke this consent at any time except to the extent that action has been taken in reliance on it.

 

Records obtained pursuant to this consent can be used only for the purposes specified.

 

DISTRIBUTION

 

Original

-

Once signed, file in the health information section of the child's case record, or in the foster/adoptive home record, or other file by CP&P, as applicable

 

Copy

-

To each provider of substance use disorder treatment records sought by CP&P.

 

Copy

-

Provide to the signer (minor or adult) of CP&P Form 11-48.