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AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION FOSTER CARE ASSESSMENT PROGRAM (FCAP)I authorize the use, disclosure and exchange of protected health information between foster parents, school personnel,
and treatment providers and the staff of the Foster Care Assessment Program, a Department of Child & Family
Services (DCFS) contractor, as provided in WA State RCW 26.44.030(7) and as outlined below.Protected health information may be disclosed by: foster parents, school personnel, and treatment providers.
Protected health information may be disclosed to and exchanged between: social workers, treatment providers and
pediatricians of the Foster Care Assessment Program (FCAP). Regarding: _________________________________________ Birth Date: ___/__/___ Patient/Client (Minor Child) PURPOSE OF DISCLOSUREThe purpose of disclosure is to assist the FCAP and DCFS in planning for my children, and/or assisting in meeting the
health needs and developing a permanency plan for this child.My Rights: I understand I do not have to sign this authorization in order to obtain health care benefits (treatment,
payment, or enrollment). I may revoke this authorization in writing. To view the process for revoking this authorization,
please read the Privacy Notice to patients posted at the facility where your information is being released. I understand
that once the health information I have authorized to be disclosed reaches the noted recipient, that person or organization
may re-disclose it, at which time it may no longer be protected under Privacy laws. EXPIRATION OF AUTHORIZATION This authorization expires on (date) OR when the following event occurs: FCAP case closure(State when you want to stop disclosing information according to this authorization). If this authorization is for the
purpose of disclosing information other than payment information to an employer or financial institution, the authorization
will be effective for no more than 90 days from the date signed or, if you specify, a period less that 90 days.