Chfs 305 Form – Fill Out and Use This PDF

Chfs 305 Form PDF Details

The Chfs 305 Form is the official Kentucky authorization document used to permit the Cabinet for Health and Family Services to disclose or use an individual's Protected Health Information (PHI). Revised in November 2021, the form is used specifically by the Department for Community Based Services, Protection and Permanency branch, and must be completed voluntarily by the individual or their legal representative.

What PHI Does the Chfs 305 Cover?

The Chfs 305 Form authorizes disclosure of a wide range of Protected Health Information, including medical history, immunization records, diagnosis and treatment details, eligibility records for public benefit programs, and substance abuse treatment records covered under 42 CFR Part 2 federal confidentiality regulations. The individual completing the form must identify which specific categories of PHI are being authorized for release.

Key Sections and Fields on the Chfs 305 Form

When completing the form, you will provide the patient's full legal name, the name and contact information of the authorized recipient, a clear description of the PHI to be disclosed, the stated purpose of the disclosure, and the expiration date or qualifying event after which the authorization ends. A dated signature confirms voluntary consent. Legal guardians completing the Chfs 305 on behalf of a minor must identify their relationship to the patient in the form.

Expiration Date and Right to Revoke Authorization

Authorization under the Chfs 305 Form expires on the date or event specified in the document. You retain the right to revoke consent at any time by sending a written revocation request to CHFS. Revocation does not affect disclosures that already occurred while the original authorization was valid. Substance abuse treatment records receive additional protections under 42 CFR Part 2 and require separate handling procedures.

Who Uses the Chfs 305 Form?

The Chfs 305 Form is typically used by individuals receiving services from Kentucky's Department for Community Based Services, parents or legal guardians of minor children in the DCBS system, caseworkers coordinating care across multiple agencies, and healthcare providers who need to share treatment records for continuity of care purposes.

For related Kentucky legal forms, see the Kentucky Living Will or the Medical Records Request Form. For general health authorization documents, see the Health Information Release Form.