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Reset FormCONSENT TO RELEASE OF MEDICAL, MENTAL HEALTH AND/OR SUBSTANCE USE RECORDSState Form 51128 (R3 / 622) DEPARTMENT OF CHILD SERVICESINSTRUCTIONS: The Family Case Manager or DCS representative

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What is consent to release of?

Consent to release of refers to the authorization given by an individual to allow the disclosure of their personal information to a third party.

Who is required to file consent to release of?

Individuals or entities that need to share personal information, such as healthcare providers, employers, or financial institutions, are required to file a consent to release.

How to fill out consent to release of?

To fill out consent to release, one must provide their personal details, specify the information to be released, list the recipient of the information, and sign and date the document.

What is the purpose of consent to release of?

The purpose of consent to release is to protect individual privacy by ensuring that personal information is only shared with authorized individuals or organizations.

What information must be reported on consent to release of?

The consent to release must report the individual's full name, contact information, nature of the information being released, purpose of the release, and recipient's details.

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