Release Of Information Form For Updated Medical Information

(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 in these matters, 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. ADOPTION PROCESS FORMS CHAPTER 0250-07-13 (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. _______________________________________________________________ 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: _____________________________