HHSA - DSS - Authorization for Release of Confidential Information

CalWORKs Employment Services
AUTHORIZATION TO RELEASE CONFIDENTIAL INFORMATION

I. PROGRAM PURPOSE – The CalWORKS Employment Service’s Program is a comprehensive statewide employment program designed to enable participants to achieve self-sufficiency through employment. The intent of the program is to provide employment and training services to adult recipients of CalWORKs cash aid.

II. REASON FOR RELEASE – To ensure you receive the widest range of CalWORKs services. Your employment counselor may need to communicate with staff from other agencies, non-profit organizations, and other departments on your behalf. All have agreed to cooperate to better serve you and to protect your confidential records. Your signature on this form gives your written consent to Nevada County Department of Social Services, CalWORKs Employment Service’s program to exchange information related to your CalWORKs services and develop a plan of activities for you. (Please indicate those agencies/individuals to be included in this release of information)
Granite Wellness (CoRR)Community Beyond ViolenceAMI HousingFamily Resource CenterNevada County Behavioral Health DepartmentConnecting PointNevada Joint Union High School District, Adult Education ProgramNevada County Child Protective ServicesNevada County ProbationSierra CollegeOther (provide name of individual, agency or organization)
Other
III. PARTICIPANT AGREEMENT/AUTHORIZATION:*

I authorize the individuals, or representatives of the participating entities indicated above, to verbally and in writing exchange any and all pertinent information about me from their automated and manual case files about my educational or training program or other activities/services related to my participation in the CalWORKs Employment Service's program with Department of Social Services staff.
IV. NOTICE OF RIGHTS - As a CalWORKs Employment Service's participant, your records are protected under the federal, state and local regulations governing confidentiality (Civil Code 56 and 1798; Welfare and Institutions Code 10850, 5540, and 5328; Education Code 49073; 42 CFR Part 2; and Health and Safety Code 123100, Evidence Code Section 992, 1010.5, 1012, 1040). Written records from your CalWORKs Employment Service's files will not be released under this authorization except as permitted or required by law. You may revoke this consent at any time. Exception: Action already taken based on the consent may not be revoked.

Federal rules restrict any use of the disclosed drug or alcohol information to criminally investigate or prosecute you.

This consent expires one year from the date you sign this form. You are entitled to a copy of this agreement.
Print Name*
Date*

MonthDayYear
Date
Signature*
Signature of Case Manager*
NEVADA COUNTY DEPARTMENT OF SOCIAL SERVICES ● P O BOX 1210 ● NEVADA CITY, CA 95959

H:\SO\WTW\Forms\WTW 500 Release Conf Info 9-16.doc
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