JV-226

Authorization to Release Health 
and Mental Health Information

This form authorizes the release of the child’s health and/or 
mental health records to the child welfare agency to ensure 
that the child receives appropriate and effective services. It 
also allows the agency to carry out its case management 
responsibilities; to monitor treatment, health-care operations, 
and billing and payment; and to inform the court of the child’s 
medical and/or mental health needs. This form complies with 
the Health Insurance Portability and Accountability Act 
(HIPAA), Confidentiality of Medical Information Act 
(CMIA), and Lanterman-Petris-Short (LPS) Act.

Fill in court name and street 
address:
Superior Court of 
California, County of

Fill in child's name and date of 
birth:
Child’s Name:

The parent, legal guardian, or Indian custodian may only
complete items     ,     ,     ,     ,     ,     , and     .
6

3

7

9

2

8

1

Date of Birth:

The child may only complete items     ,     ,     ,     ,     ,     , 
and     . 

2

5

4

1

7

6

8

Case Number:

1

I am the
a.
b.
c.
d.

Parent 
Legal guardian
Indian custodian
Child, and I am eligible to consent 

2

I give the following child welfare agencies and individuals permission to release health 
information about        me       the child 

3

I am the parent, legal guardian, or Indian custodian and I authorize release of the 
following medical information. Mental health information contained in the medical file 
may not be released. 

I understand that I may refuse to sign this form. I understand that the child cannot be 
denied treatment just because I choose not to sign. (Check all that apply):
a.
b.
c.

Diagnoses
Medical histories 
Medications

Immunizations
Lab reports
X-ray reports

d.
e.
f.

None

g.
h.

Judicial Council of California, www.courts.ca.gov 
Revised July 1, 2013, Optional Form

JV-226, Page 1 of 3

Authorization to Release Health and 
Mental Health Information
(Dependency)

Child’s name:

Case Number:

4

If the child is between 12 and 18 years old, the child may authorize release of the following 
information. 

I discussed the contents of this form with my attorney before deciding whether or not to 
sign this form. I understand that I may refuse to sign this form. I understand that I 
cannot be denied treatment just because I choose not to sign.

I am the child and I authorize the following information to be disclosed (check all that 
apply):
a.

e.

HIV information, including test 
results
Mental health diagnoses
Outpatient mental health treatment 
or counseling records
Records regarding sexually 
transmitted diseases

f.

b.
c.

d.

Records regarding infectious, 
contagious, or communicable disease 
if  law or regulation requires the 
disease or condition to be reported to 
the local health officer
None

5 Only the child, regardless of his or her age, may authorize release of the following 

information.

I discussed the contents of this form with my attorney before deciding whether or not to 
sign this form. I understand that I may refuse to sign this form. I understand that I 
cannot be denied treatment just because I choose not to sign.

I am the child, and I authorize the following information to be disclosed (check all that 
apply):
a.
b.
c.

Pregnancy records
Reproductive health records
Sexual assault treatment records, 
if the child consented to this treatment

None

d.

I give permission to release         my          the child’s     health information specified by the 
checked boxes in items 3, 4, and 5 and to discuss them with (name of child welfare 
agency):                                                                                                                                    .  

I understand that the child welfare agency may share or be required to share        my        the 
child’s      health and/or mental health information with certain persons or agencies for 
purposes of treatment, health-care operations, billing and payment, or as otherwise required 
by law, without having to ask for my permission.

I understand that if this health and mental health information is disclosed to someone who is 
not legally required to keep it confidential, it may be redisclosed and may no longer be 
protected.

6

7

Revised July 1, 2013

JV-226, Page 2 of 3

Authorization to Release Medical and 
Mental Health Information
(Dependency)

Case Number:

Child’s name:

a.
b.

c.
d.

8

9

I request a copy of this form.  
I am the child and understand that I do not have to give this form to my parent or 
legal guardian.       
I do not want a copy of this form.
I request a copy of the records that will be released.

I understand that I may revoke this authorization by writing to (name and address  of 
person to whom revocation should be directed):

Once this person receives my written request, this authorization will be revoked, but only 
to the extent that the authorization has not already been relied upon to release health 
information.

10 This authorization automatically ends one year from date of signature.

11

This form is not intended to abrogate the rights of court-appointed counsel for the child to 
access records pursuant to Welfare and Institutions Code section 317(f) or court order.

Date:

(TYPE OR PRINT NAME OF 
PARENT/LEGAL GUARDIAN)

(SIGNATURE)

(TYPE OR PRINT NAME OF CHILD )

(SIGNATURE)





IMPORTANT: PLEASE READ
The health-care provider may refuse to release the records if he or she determines 
that access to the child’s records would have a detrimental effect on the provider’s 
professional relationship with the child or the child’s physical safety or psychological 
well-being.

Revised  July 1, 2013

JV-226, Page 3 of 3

Authorization to Release Medical and 
Mental Health Information
(Dependency)