AUTHORIZATION RELEASE OF CONFIDENTIAL SUBSTANTIATED

MAINE CHILD ABUSE AND NEGLECT RECORDS INFORMATION

 

Agency/Provider to receive this information:                                                                  Agency ID#:  2630

 

Timothy Folley

Social Significance LLC

305aa Main Street

Waterboro, ME  04087

 

 

I, __________________________, authorize the Maine Department of Health and Human Services to release

 (Please print clearly)

confidential information to the above agency regarding whether I have been involved in a substantiated Maine

Child Protective Services case and the nature of that involvement.

 

I understand that:

o   This release may be revoked by me in writing at any time, except for information that has already been released.  For details contact Child Protective Intake at 1-800-452-1999 x2.

o   Disclosure will include the determination by the Department of any specific abuse/neglect to a child by me and any actions taken by me or the Department.

o   I may make a statement for the DepartmentÕs record regarding the findings about me and any actions taken by me at that time or later to deal with the problems identified.  Such statement becomes case record information for this or any other requests or authorizations for disclosure. For details, contact Child Protective Intake 1-800-452-1999 x2.

o   This information will be used as part of the above agencyÕs assessment of my suitability to provide services for children and families they serve.

o   This information is subject to continuing confidentiality as provided by Maine statute, 22 M.R.S. ¤4008.

o   This release will expire upon the disclosure of the information as authorized.

o   The fee for this process is $15.00 per person as authorized by 22 M.R.S. ¤ 4008(6) and 10 148 DHHS Chapter 202 (2004), payable to Treasurer State of Maine.

 

PLEASE DO NOT LEAVE ANY SPACES BLANK

 

DATE OF BIRTH:_________________ALIASES (including maiden):_____________________________________________

 

SIGNATURE:_______________________________________________________________DATE:______________________

 

MAINE ADDRESS:______________________________________________________________________________________

 

RESULT BELOW (To be completed by DHHS):

 

As of ______________, this person was NOT INVOLVED in a substantiated Maine Child Protective Services case.

 

_____________________________________

DHHS, OCFS, Child Protective Intake Staff

IF RESULT AREA IS BLANK, SEE REVERSE SIDE/ATTACHMENT_

                 Child Protective Intake 1-800-452-1999 x2, TTY Users: Dial 711 (Maine Relay)                             Updated 2012