ISK Record Release Request

Date of Request *

*Put in date of submission of the form.

I hereby request a copy of my Record(s) containing the following information. *

First

Last

Date of Birth: *

SSN: *

Check all that Apply:

Evaluation/Assessment Records and Information
Treatment Planning & Services Records/Information
Information on current status of services provided
Admission/Discharge Information
9th Judicial Circuit Court Records
FIA Records
Family Assessment
School Records (Including IEPs & Psych Evals)
*Medical/Health Records/Info (including medications, diagnostic info) •Separate authorization required for thefollowing Serious communicable diseases: HIV, AIDS, ARC, TB, and Hepatitis
**Drug Usage/History ** Disclosure governed by or prohibited by 42

CFR Part 2

Treatment Attendance (CA)

read at Request

Other:

My purpose for this disclosure is: *

I would like the records mailed to my attention at the following address:

I would like to pick up my requested records in person, please notify me at the following phone number when the request is complete:

My signature digital below means that I have read this form and/or have had it read to me and explained in language I can understand. I know what information will be disclosed and give my voluntary consent to its release. *

Date Signed *

Who signed the form: *

Individual
Parent
Guardian/Legal Representative

Witness digital signature here:

Date Signed (copy)