Fees And Charges For Non-Identifying Information

(1) The fee for processing an initial written request for records pursuant to this Chapter shall be $45.00. (2) Fee Waiver (a) Fee waiver determinations will be made only upon request of the individual after notice by the Department of the fee requirement following receipt of the person’s written request. (b) No fee will be charged to any person who receives, or whose family unit currently receives, Temporary Assistance for Needy Families (TANF) or any other means-tested cash assistance program which may replace TANF, or Food Stamps or any other means-tested food assistance program which may replace the Food Stamp program, or if the person currently receives Medicaid or TennCare which is based upon a means test which places the person below Federal Poverty Guidelines as published in the Federal Register, or if the person receives any other means-tested medical assistance program which is based upon a means test which places the person below Federal Poverty Guidelines as published in the Federal Register, or if the person currently receives Supplemental Security Income (SSI) under Title XVI of the Social Security Act. (c) The person requesting the fee waiver will be required to provide written verification of current eligibility for any of the above designated programs from the administering agency. (d) If the person cannot show such verification of eligibility under the above programs, the person requesting the fee waiver will be required to complete a sworn declaration of the source and amount of income and resources on a form provided by the Department. If the person’s family unit’s income, based upon its size, does not exceed the current threshold level of income in the Federal Poverty Guidelines as published periodically in the Federal Register and if the family unit’s non-exempt resources do not exceed $1,000, the fee for search will be waived. (3) Payments for release of non-identifying information shall be made to the Fiscal Services Section of the Department of Children’s Services, at the address given by the Department. Payments by mail may be made by personal check, cashier’s check, or money order payable to the Department of Children’s Services at this address. Cash will be accepted only when hand-delivered to the Fiscal Services Section at the address given by the Department. RELEASE OF NON-IDENTIFYING INFORMATION FROM RECORDS CHAPTER 0250-7-11 OF ADOPTIONS AND TRANSMITTAL OF MEDICAL INFORMATION REGARDING CERTAIN PERSONS AFFECTED BY ADOPTIONS (4) All fees or other charges shall be deposited with the State Treasurer in accordance with the provisions of T.C.A. § 9-4-301. (5) Fees for service will be charged for each service requested on behalf of, or by each individual who requests service. Authority: T.C.A. §§ 37-5-105, 36-1-101 et seq., Section 13 Public Chapter 1079 (1996), and Public Chapter 1054 (1996). Administrative History: Original rule filed September 7, 2001; effective November 21, 2001. 0250-7-11.05 APPENDIX-FORMS (1) The following form is used when a request for medical information is made by an adopted person or by a biological or legal relative or the legal representative of the adopted person and they have provided written evidence from a licensed health care professional or a licensed health care facility of a medically established need for additional or updated medical information pursuant to T.C.A. § 36-1-135, and the Department of Children’s Services, is contacting the persons who have access or who may have access to those records. (2) This information shall be confidential and shall only be disclosed as provided by T.CA. § 36-1-101 et seq. (3) Form: RELEASE OF INFORMATION FOR UPDATED MEDICAL INFORMATION TENNESSEE CODE ANNOTATED, § 36-1-135(c) This Release of Information should be used when a request for medical information has been made by an adopted person or by a biological or legal relative or the legal representative of the adopted person and they have provided written evidence from a licensed health care professional or a licensed health care facility of a medically established need for additional or updated medical information about an adopted person, or their biological or legal relatives and the Department of Children’s Services, is contacting the persons who have access to or have or may have knowledge of such information. See, T.C.A. 36-1-135. I, __________________________________, (Name of Person Executing the Release) have been told by the Tennessee Department of Children’s Services that a person eligible to request updated medical, psychological, or psychiatric information has requested additional or updated medical, psychological, or psychiatric information to which I may have access or of which I may have knowledge. I understand that if I have authority to release such information, that such release is entirely voluntary on my part. 1. I hereby release the following specific information to the Tennessee Department of Children’s Services and its authorized agents to provide such information about me to the treating professionals or health care facilities for the purpose of assisting with the medical, psychological, or psychiatric care of the requesting party (Attach Additional Sheets if Necessary): ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ____________________ 2. Names and addresses of Treating Professionals or Health Care Facilities from Whom the Information May Be Released Pursuant to My Approval (Attach Additional Names if Necessary): a. _______________________________________________________________ RELEASE OF NON-IDENTIFYING INFORMATION FROM RECORDS CHAPTER 0250-7-11 OF ADOPTIONS AND TRANSMITTAL OF MEDICAL INFORMATION REGARDING CERTAIN PERSONS AFFECTED BY ADOPTIONS b. _______________________________________________________________ c. _______________________________________________________________ d. _______________________________________________________________ e. _______________________________________________________________ f. _______________________________________________________________ 3. Other than the specific information given above, I wish to share other medical information about me and/or other relatives: (If information is given about other relatives, please specify their relationship to you.) ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________________________________________________________________________ ________________________ 4. This Release Shall Expire in four (4) months from date of my signature unless otherwise stated here ____________. Thereafter a new release must be executed for further release of additional or updated medical information. This the ___ day of __________, 20___. Please Print: _____________________________ Name of Person Signing Release Signature:_______________________________