Consent for Release of Information & HIPPA Disclosures

Catholic Charities Young Learners Programs
Child and Adolescent Intensive Outpatient Day Treatment

Client Name:
Any other Names (Describe)
Date of Birth:    
Street Address:
City / State / Zip
I understand that my records are protected by data practices laws and the Health Insurance Portability and Accountability Act of 1996 (HIPAA)
I understand that alcohol and drug treatment records may be further protected by federal regulations (see 42 C.F.R. part 2.)
I understand that only the information and records indicated below will be released or obtained.
I understand that the information will only be released to or obtained from the persons or entities indicated below.
I understand that this consent does not authorize the recipient of the information or records to re disclose the information or records to anyone else unless authorized by law.
I understand that the information will only be used for the purposes indicated below.
I understand that the agency/entity holding the information to be disclosed may not withhold treatment, payment, enrollment, or eligibility for benefits if I do not sign this authorization
I understand that it is possible that the information disclosed using this authorization will be re disclosed and will no longer be protected by federal law. However, Minnesota law prohibits the re disclosure of this information without further authorization
A photocopy of this form shall be treated as the original.
Name of Agency / Entity: Young Learners Programs – Catholic Charities of the Diocese of St. Cloud
Name of Worker: Kara Rogers and Young Learners Program Mental Health Staff
to: Obtain records from Release records to (or) Both
Name of Worker
Title of Worker:
Agency / Entity:
Street Address:
City / State / Zip:
I authorize records to be obtained and/or released for services covering dates:
Admission / Intake Summary / Diagnostic Assessment
Discharge or Closing Summary
Medical History / Physical Exam / Laboratory Reports
Psychological Testing or Evaluation
Psychiatric Evaluation
Progress Reports, Treatment Records, ER Reports
Social History
Social Service Records
I wish to withhold information regarding:
The use of the requested records will be:
To coordinate services To participate in consultation  
To acknowledge referral To transfer treatment  
For legal purposes To access insurance information  
Other (specify)
The requested information may also be released:
Verbally – conversation with contact person In writing – copies of original records may be sent
I understand that this authorization will remain in effect for a maximum of one year from the date of signature and that I may revoke this authorization by providing a written notice of this revocation to the agency/ entity holding the information to be disclosed, who is bound to comply with the request if the information requested in this authorization has not yet been provided.
Client Signature
Parent or Guardian or Authorized Representative Signature (if Necessary)
Relationship to Client:  
Witness or Agency Representative:

Young Learners Program
Kara Rogers,
Clinical Supervisor

Ph: 320.253.5828 (Ext. 5824)

Tim Lieser,
Director, Residential & Day Programs
1726 7th Ave S
St. Cloud, MN 56301

Ph: 320.650.1591
Fx: 320.650.1599

Early Childhood Services
St Cloud Area School District 742
Alicia Jepsen,
Special Education Supervisor
3015 3rd St N
St. Cloud, MN 56303

Ph: 320.253.5828
Fx: 320.529.4320