Transcription of Child and Family Team Authorization for Use ... - …
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Child and Family Team Authorization for Use ... - …
Child and Family Team Authorization for Use of Protected Health and Private Information Child NAME: _____ DATE OF BIRTH: _____ MEDI-CAL CLIENT IDENTIFCATION NUMBER (CIN): _____ PLACEMENT AGENCY WORKER: A. I allow the following health care providers (including mental health care providers) to share all information related to my medical history, treatment, and health (including mental health) permitted under federal and state law with persons designated as members of my Child and Family Team for purposes specified in Welfare & Institutions Code 16501(a)(4). These purposes include, but are not limited to, providing input into the development of my Child or youth client plan, Family plan, and/or my placement decisions.
C. I allow the following members of my Child and Family Team to receive and use information from my health care providers for the purpose of my Child and Family Team.
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