AUTHORIZATION FOR INFORMATION JD-CL-46 Rev. 7-12 (See Instructions and "Notice to Receiver C.G.S. §§ 10-154a, 17a-693, 17a-694, of Information" on back/page 2) 31-128f, 52-146b to 52-146o From (Full name of person giving permission to give information or asking for information) STATE OF CONNECTICUT SUPERIOR COURT www.jud.ct.gov Information needed by (Date) 1. Address I give the Judicial Branch permission to GET the information in section 4 from: Name T Address 2. (Fill out the name and address boxes) to GIVE the information in section 4 to: (Fill out the name and address boxes) T 3. Information About: Name (Full name of Subject of Record) (Check if authorization is for information concerning a minor child) Instructions: The person completing this authorization should be advised that this form may not be used to give both psychotherapy notes and other types of health information. If this form is being used to give psychotherapy notes, a separate form must be used to give any other health information. Authorizations to give sensitive health information (such as HIV/AIDS or substance abuse) should be initialed by the requestor. ("x" all that apply): Date of birth 4. Type Of Information: Entire Medical Record Only information related to (specific diagnosis, injury, operation, etc.) Only the period of events from Billing Records psychotherapist-patient privilege) School Transcript Other: to I specifically give permission to give the following sensitive information from my health record. (Initial all that apply) Substance Abuse (Alcohol/Drug) Confidential HIV/AIDS Related Information Mental Health (Other than psychotherapy notes) Sexually Transmitted Disease Genetic Testing Psychotherapy Notes ONLY* (by checking this box I am waiving any * PSYCHOTHERAPY NOTES means notes recorded (in any form or medium) by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of an individual's medical record. 5. Purpose Of Authorization if this Authorizes the Judicial Branch to Get Information: This request is being made at the request of the individual for purposes related to the case identified in this section which may include, but not be limited to, court ordered investigation or evaluation, supervision and mediation or negotiation: Court Judicial Geographical District Area Number If Supervision, show type and duration Juvenile Matters At (Town) Docket number 6. If this Authorizes the Judicial Branch to Get Information, please send it to: Judicial Branch Division Name of person requesting information Telephone number Office or court mailing address 7. Purpose Of Authorization if this Authorizes the Judicial Branch to Give Information: (Specify) 8. Statement of Authorization (See explanation on page 2) closure. I understand that I may inspect or have copies made of the information to be I ask and give permission to the person or institution named above to release to the used or disclosed (excluding psychotherapy notes). I understand that under applicable Recipient specified above copies of the information requested in Sections 3 and 4 of this law, the information disclosed under this authorization may be subject to further form and I give permission to the Recipient to release that information, whether obtained disclosure by the recipient and thus, may no longer be protected by federal privacy by this or an additional authorization required by the person or institution named in regulations. I understand that I may revoke this authorization, in writing, at any time by Section 2, by making it available for inspection, including any sensitive information sending such written notification to the person or institution named above, except to the identified in Section 4, to the Court, to parties to the case, to attorneys in this case, and extent that action has already been taken in reliance on it; or, except in the case of to any appointed Guardian Ad Litem. These recipients must not further disclose this disclosure to those persons within the criminal justice system who have made my information except that non-sensitive health information may be disclosed for legitimate participation in a program or service provided by the person or institution named above trial and trial preparation purposes related to this case. I have read this form/had this a condition of (1) the disposition of any criminal proceedings against me, (2) my release form read to me and I understand the purpose of this release of information. I from custody or (3) my probation. My permission, unless expressly revoked earlier, understand that signing this is voluntary. My treatment, payment, enrollment in a health automatically expires as stated below. plan, or eligibility for benefits will not be conditioned on my authorization for this disXXXXXXXXX Give date, event or condition on which your permission ends, which can be no later than the final disposition of your case Signature or person giving permission (If minor, signature of parent or guardian, unless Section 19a-592 of the Connecticut General Statutes applies) Date signed Signature of Witness If signed by a legal representative, check relationship to subject of record and provide written proof of your authority Executor Power of Guardian Conservator Attorney (Parents do not need documentation): Parent of Estate DISTRIBUTION: ORIGINAL - Party holding requested information COPY 1 - C.S.S.D. Office or Court File COPY 2 - Authorizing individual American LegalNet, Inc. www.FormsWorkFlow.com Instructions to Judicial Branch Staff Asking for Permission to Get Information 1. Fill out sections 1, 3, 4, 5 and 6. 2. In section 2, check the "GET" information box and enter the name and address of the hospital, school, physicians, clinic, laboratory, pharmacy, insurer or other health care provider that has the information. 3. Have the person whose information is being asked for fill out section 8 and have them sign the form in front of a witness. 4. Give a copy of the form to the person giving permission. Instructions to Person Asking the Judicial Branch for Information 1. Fill out section 1. 2. In section 2, check the "GIVE" information box and enter your name and the address where the information is to be sent. 3. Fill out sections 3, 4 and 7. 4. Have the person whose information is being asked for fill out sectio