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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:

Volume:

X

Forms

Chapter:

A

Forms

2-9-2018

Subchapter:

1

Forms

Issuance:

26.15

CP&P Form 26-15, Authorization for Release of Information

 

Click here to view or print CP&P Form 26-15.

 

Click here to view or print form in Spanish, CP&P Form 26-15(S).

 

PURPOSE AND USE

 

The form is used to obtain authorization to release:

      CP&P records about the client and/or the client's minor children to another person or agency.

      Information about the client and/or the client's minor children from another agency or person to CP&P.

      Information about prospective resource family parents and their children.

Release of client information in CP&P records is in accordance with the policy outlined in CP&P-IX-G-1-100, Collection and Disclosure of Client Information.

For release of health related information use CP&P Form 11-90, HIPAA Authorization to Disclose Information.

 

INSTRUCTIONS FOR COMPLETING THE FORM

 

The Resource Family Support Worker/Agency Representative completes the CP&P Form 26-15 as follows:

1.    Enter the name of the "releasing" agency or person. If CP&P is the "releasing" agency, enter "CP&P."

2.    Enter the name of the requesting agency or person.

3.    Enter the name of the client, and or the name of each child for whom the information is requested.

4.    Ask the parent(s) to sign his/her name in the space provided to indicate authorization.

5.    Enter the date the authorization is signed.

6.    Sign and date the authorization and enter your telephone number and office address.

 

DISTRIBUTION

 

Original          -     

Resource family parent's home record

Copy             - 

Agency or person releasing the information. If CP&P is the releasing agency, the original is filed in the case record.

Copy             - 

Prospective resource family parent

Copy             - 

Case record