AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION. THE XXXXXXXXX XXXXXXX XXXXXX XXXXXXX XXXXXXX, XX. JUVENILE JUDGE CHIEF JUVENILE OFFICER 65th DISTRICT COURT JUVENILE PROBATION DEPARTMENT EL PASO COUNTY EL PASO COUNTY Name: Date of Birth: Social Security Number: I authorize the release of all confidential records and information pertaining to TCIC/NCIC Records / Police / Records / Sheriff’s Records concerning myself to the 65th Judicial District Court and to the El Paso County Juvenile Probation Department. TCIC/NCIC/Police/Sheriff’s Records Signature Date El Paso County Juvenile Probation Department TCIC/NCIC CONTRACTOR RECORDS CHECK REQUEST REQUESTED BY: APPROVED: DIRECTOR DATE REQUESTED: Criminal Records Check Requested on: NAME DOB SSN 1.
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION. THE XXXXXXXXX XXXXXX X. XXXXXXXXX XXXXX XXXXXXXX JUVENILE JUDGE CHIEF JUVENILE PROBATION OFFICER 65th DISTRICT COURT EL PASO COUNTY EL PASO COUNTY JUVENILE PROBATION DEPARTMENT Name: Date of Birth: (PRINT NAME) Social Security Number: I authorize the release of all confidential records and information pertaining to TCIC/NCIC Records / Police / Records / Sheriff’s Records concerning myself to the 65th Judicial District Court and to the El Paso County Juvenile Probation Department. TCIC/NCIC/Police/Sheriff’s Records Signature Date EL PASO COUNTY JUVENILE PROBATION DEPARTMENT TCIC/NCIC CONTRACTOR RECORDS CHECK REQUEST REQUESTED BY: APPROVED: DIRECTOR PURPOSE: COMPLIANCE CONTRACTUAL REQUIREMENT DATE REQUESTED: Criminal Records Check Requested on: NAME DOB SSN 1.
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION. I authorize Psychological Associates to disclose and make available information regarding my mental health status to my insurance company in written form or verbally for the purposes of reimbursement. I understand that this information may include, but is not limited to the following categories: clinical diagnosis; details of psychosocial history and description of my present functioning; dates of service, treatment plans and goals. I recognize that Psychological Associates cannot guarantee the confidentiality of my records when they are released to third party payers. I understand that this data may remain in a data bank which could be called upon at some future time when I apply for another health insurance policy, life insurance policy, or disability insurance policy. Signature of person/guardian releasing information Date Name:_____________________________________ Address:___________________________________ ______________________________________ _____________________________________ _______________________________________ Phone:______________________________________ Phone:____________Fax:______________ Primary Care Provider Behavioral Health Provider Date of Birth:_______________ Member: Name:______________________________________ Insurance: I, (print member name and address) _____________________________________________________ _______________________________________________________ give permission to_________________________and___________________________________ (Behavioral Health Provider) (Primary Care Provider) to exchange the following information for the purpose of coordinating my treatment, care and follow up:
