I hereby authorize the Department for Community Based Services in the Cabinet for Health and Family Services to disclose and use the specified information below.
Submit within: ten (10) days to the Cabinet for Health and Family Services, Department for Community Based Services, Records Management Section
Where to send: 275 East Main St., Section 3E-G, Frankfort, Kentucky, 40621, OR submit completed form with legible ID to CHFSDCBS.RMS@ky.gov
Expires: I understand this authorization will expire in ninety (90) days.
Revoking: I understand I have the right to revoke this authorization at any time, however I must do so in writing.
Purpose: The purpose for disclosure is: (Note: Must complete, Do Not Leave Blank)
ID: Please attach a copy of photo ID for verification
| Question | Answer |
|---|---|
| Form Name | CHFS-305 |
| Full Title | Authorization for Disclosure of Protected Health Information |
| Issued By | Kentucky Cabinet for Health and Family Services |
| Form Revision | November 2021 |
| Form Length | 2 pages |
| Fillable? | Yes |
| Fillable fields | 30 |
| Governing Regulation | 42 CFR Part 2 (substance abuse records) |
| Avg. time to fill out | 5 min |
| Edition | 11/2021 |
| Issuing agency | Cabinet for Health and Family Services |
| Filing deadline | Within ten (10) days |
| Other names | CHFS-305, CHFS 305, CHFS305, Form CHFS-305, Form 305, Authorization for Disclosure of Protected Information |
| Official source | CHFS-305 (Rev 11/2021), Cabinet for Health and Family Services |
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