Form 1022, Authorization to Disclose Information Including Protected Health Information for Referral to Another Agency/Organization

Effective Date: 12/2009

Availability

English PDF: 1022.pdf

Spanish Word: 1022-S.doc
Spanish PDF: 1022-S.pdf

Instructions

Updated: 12/2009

Note: Use of Form 1022 is not required for use by DADS local office and contractor staff, but rather, it is a tool for establishing effective referral protocols between DADS programs and other community partners. DADS local office and contractor staff may opt not to use Form 1022 and continue to use existing release of information forms. However, when using existing forms and when making referrals to DADS partner agencies and/or other community agencies and organizations, local office and contractor staff must seek to share information confidentiality and in a manner that is seamless, efficient and allows the individual to seek additional services without having to repeat basic information between or among agencies.

Purpose

To serve as the individual's authorization to release information, including protected health information, for the purposes of:

  • obtaining information to establish eligibility for DADS programs;
  • sharing information between programs within DADS;
  • sharing information with other agencies that offer benefits for the individual; and
  • eliminating barriers for individuals to receive services through multiple programs and agencies.

Procedures

When to Prepare

Ask individuals to complete and sign Form 1022 at the time of the initial and/or assessment. Individuals receiving services at a regularly scheduled follow-up or reassessment should complete Form 1022 if one is not on file. The individual is not required to complete and sign Form 1022 in order to apply for and receive benefits from DADS.

Number of Copies

Complete one original for each individual. The form must be signed by one of the following:

  • individual or responsible party; or
  • personal representative (for release of protected health information).

Transmittal

Provide an original of Form 1022 and the request for services via secure e-mail, fax, mail or the client to another program or agency. File the original or a copy of Form 1022 in the appropriate section of the case record.

Form Retention

Retain the original or a copy of Form 1022 for three years from the expiration date of the release.

Detailed Instructions

Section I

Name — Self-explanatory.

Case No. — Enter the individual's case number.

Section II – To be completed by the individual.

I authorize __________________ to disclose information... — Enter the name of the person or agency authorized to release information.

Check one of the following: —

Mark the first box if there are no restrictions on the type of information to be released.

Mark the second box to limit the release of information to specific items. Enter the type of information, such as type or amount of benefits, amount of income, or degree of disability.

I   □ do   □ do not   authorize the disclosure of ... — Mark do or do not to authorize the release of information regarding HIV/AIDS or alcohol and drug abuse treatment. Mark one or both boxes if information regardign such treatment can or cannot be released.

Expiration Date, Event or Condition — Enter a date, event or condition when the authorization to release information will expire. This date will be the expiration date unless the authorization is revoked. Unless the individual specifies a date, the authorization can be for a year.

Signature – Individual or Personal Representative — The individual or his personal representative must sign the form.

Date — Enter the date the individual or his personal representative signed the form.

Authority of Personal Representative — If a representative signs for an individual, the representative must describe why his authority to represent the individual. (Refer to the following program handbooks for definitions: Case Manager Community Based Alternatives (CBA), Section 1854; In-Home and Family Support Program (IHFSP), Section 10840; and Community Care for the Aged and Disabled (CCAD), Section 1150.

Signatures of Witnesses — If the person requesting the release of case information cannot sign his/her name, two witnesses to his/her mark (X) must sign. Accept one witness signature in circumstances where it is not possible to obtain two witness signatures. Document the reason in the case record.

Section III

Review the Notice to Individual section with a thorough explanation of the individual's rights regarding release of information, release of health information and that health information will no longer be protected by medical privacy laws.

Attachment A

Ask the individual to check the agencies where information may be disclosed and add any additional persons or agencies to receive the disclosure of information. If it is acceptable to the individual for his information to be shared with any agency deemed necessary for the duration of the release, he may simply check the first box, General Release, to indicate this.

Usage Guidelines

  1. Individuals should be asked to complete and sign Form 1022 at the time of the initial assessment. Individuals receiving a regularly scheduled follow-up or reassessment also should be asked to complete and sign Form 1022 if one is not on file. The following staff may assist the individual in completing the form:
    • DADS case managers
    • LA service coordinators or intake staff
    • AAA care coordinators
    • AAA benefits counselors
    • AAA caregiver specialists
    • Aging and Disability Resource Center system navigators
  2. When the individual’s signature on a release form is required by program rule or policy, ensure the individual signs Form 1022. If verbal release is permitted by rule or policy and this is the manner by which authorization is being acquired (for example, by telephone), staff should make a note to that effect, including the date and time, and sign his/her own name.
  3. After completing Form 1022, place the original in the individual’s case file.
  4. When making an inquiry to a local DADS Long-Term Services and Supports (LTSS) office, Area Agency on Aging (AAA) or Local Authority (LA) about an individual already enrolled or waiting to be enrolled in that agency’s program(s), send a copy of the completed Form 1022, along with the inquiry, by regular mail, fax or e-mail (for e-mail, use Voltage e-mail encryption, wherever possible). Note: Examples of an inquiry include when staff making the inquiry need to know (1) if the individual is already receiving services from another DADS program, or (2 ) if the individual is on a certain interest list, including his/her location on it.
  5. When receiving an inquiry from a local DADS office, AAA or LA about an individual already enrolled or waiting to be enrolled in that agency’s program(s), ensure that the referring agency has provided a copy of a completed Form 1022 and then follow-up with the agency with the requested information. Note: This guideline confirms that Form 1022 provides the agency the authority to provide DADS partner agencies the requested information.
  6. When referring the individual to another agency, send a copy of the completed Form 1022, along with other relevant information (referral form, intake, assessment, etc.) to the second agency, using any of the transmittal methods listed in No. 4, above.
  7. When receiving a referral and the completed Form 1022 from another agency (including other relevant information, such as an intake), staff should — to the extent possible — either accept these documents in place of his/her agency’s own forms, or transfer the information to the necessary documents. Note: This practice seeks to reduce the requirement for the individual to have to repeatedly provide basic information from one agency to the next.
  8. When referring the individual to a third agency, follow the steps in No. 6 above. If the agency is not noted in Appendix A in the original Form 1022, ask the individual to either check that agency or fill in the name of the agency under Other and provide his/her initials. Note: This practice ensures the individual’s release information continues to be updated as he/she navigates through the service system.
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