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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: 2-14-2018

Volume:

X

Forms

Chapter:

A

Forms

Revised Date: 2-4-2019

Subchapter:

1

Forms

Issuance:

11.91

CP&P Form 11-91, Request for the Disclosure of Health Records or Information

 

 

Click here to view, complete, or print a CP&P Form 11-91, Request for Disclosure of Health Records or Information.

 

Click here to view, complete, or print a CP&P Form 11-91(S), Request for the Disclosure of Health Records or Information (Spanish).

 

WHEN TO USE IT

 

Use CP&P Form 11-91 to request from outside medical providers the health records of a child in CP&P's care, when the records or information are required to obtain, provide or coordinate the medical treatment of that child.  It is not to be used to request substance use disorder treatment records or psychotherapy notes.

 

HOW TO USE IT

 

When seeking to obtain medical records or information necessary to provide, obtain or coordinate the medical treatment of a child in CP&P's care, the assigned worker is responsible for:

·       specifying the information sought, and

·       providing an address (mailing or electronic) for delivery of that information.

 

Complete the form on-line, print, and sign or print the form, complete by hand, and sign.  Mail or e-mail the completed form to the medical provider.

 

Non-DCF mailing and email addresses may not be used to receive health information under any circumstances.

 

DISTRIBUTION

 

Copy 1   -   Send to each provider of medical or health records sought by CP&P.

 

Copy 2   -   File in the health information section of the child's case record or in the resource home record or other file maintained by CP&P, as applicable.