Records Request Form

Community Child Guidance Clinic welcomes records requests from parents, guardians, service providers, attorneys, and other authorized parties seeking information related to a current or former student or client. Please complete the form below as thoroughly as possible so we can review and process your request. After submission, CCGC may contact you for additional signatures, identity verification, or other documentation needed to release records in accordance with privacy laws and clinic policy.

Who are the documents being released to?

I acknowledge that typing my name below constitutes an electronic signature and provides my consent to the terms of this request.

I, on behalf of myself, or as a parent or guardian, authorize Community Child Guidance Clinic to release to the above information:  

I, on behalf of myself, or as a parent or guardian, am requesting access to protected health information that is currently maintained by Community Child Guidance Clinic. I understand that my rights regarding this request for access are set forth in Community Child Guidance’s Notice of Privacy Practices.  By signing this form, I agree to pay the reasonable costs of preparing, copying, mailing or other supplies and labor associated with my request, up to the maximum amount allowed by law. Current Rate $0.55 per page.

Please be advised- To release information, additional signatures or documentation are often required. Promptly respond to any communication from CCGC or Docusign regarding this request, so that it may be completed in a timely manner.

Important information about this authorization:

• This authorization remains in effect, unless specifically withdrawn by the parent or guardian.
• In accordance with Community Child Guidance Clinic’s Notice of Privacy Practices this authorization may be revoked by me at any time, with the exception of that information which has already been released, by providing a signed, written notice to Community Child Guidance Clinic.
• Treatment provided by Community Child Guidance Clinic is not conditional upon my signing this release and I may refuse to sign.
• The potential exists for the information to be subject to redisclosure by the recipient and no longer be protected by Connecticut or Federal law.
• Protected Health Information may be transmitted  electronically (i.e. secure email, text, and/or client portal)

AUTHORIZATION FOR RELEASE/USE OF PROTECTED HEALTH INFORMATION

Any information released by Community Child Guidance Clinic is subject to the following stipulations:

• State of Connecticut law contained in Chapter 899 of the Connecticut General Statutes prohibits those receiving psychiatric information from making further disclosures of it or for using it for any purpose other than indicated on the release without the specific written consent of the person to whom it pertains, or as otherwise permitted by law.
• Any information that is protected by the HHS Confidentiality of Alcohol and Drug Abuse Client Records Regulations (42CFR Part 2) prohibits you from making any further disclosures of this information unless further disclosure is expressly permitted by the written consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2; a general authorization for release of medical or other information is not sufficient for this purpose.  These rules restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse client.
• In the event that information released constitutes confidential HIV-related information protected under Connecticut law State law prohibits you from making any further disclosure of it without the specific written consent of the person to whom it pertains, or as otherwise permitted by said law.  A general authorization for the release of medical or other information is not sufficient for this purpose.

Programs: CCGC School, Outpatient and IICAPS

Address: 317 North Main Street, Manchester, CT, 06042

School Phone: (860) 646-0502
Outpatient, IICAPS Phone: (860) 643-2101
Fax: (860) 645-1470

Hours:
Mon: 8:00am to 6:00pm
Tue: 8:00am to 8:00pm
Wed: 8:00am to 6:00pm
Thu: 8:00am to 8:00pm
Fri: 7:00am to 5:00pm

Programs: North Star

Address: 1075 Tolland Turnpike, Manchester, CT, 06042

Phone: (860) 643-2101
Fax: (860) 432-8333

Hours:
Mon: 9:00am to 5:00pm
Tue: 9:00am to 5:00pm
Wed: 9:00am to 5:00pm
Thu: 9:00am to 5:00pm
Fri: 9:00am to 5:00pm