MISSOURI DEPARTMENT OF SOCIAL SERVICES CHILDREN'S DIVISION AUTHORIZATION FOR RELEASE OF NON-MEDICAL RECORDS BY/TO CHILDREN'S DIVISION
In signing this release, you are authorizing the Children’s Division, or another person or organization with whom you are acquainted to release or obtain information regarding you or your family in the course of your involvement with the division. All parties involved should be aware that this release is for use with NON-MEDICAL records. This release is not HIPAA-compliant and should not be used for any records containing health information protected by the Health Insurance Portability and Accountability Act (HIPAA).
I,	do hereby authorize and request the:
(Name of Individual, Guardian, Legal or Personal Representative)
Children's Division
Family Support Division
School
(Name of School)
(Address of School)
Other Party
(Specify from whom information is requested)
(Address)
To release records pertaining to:
(Name of Individual, Guardian, Legal or Personal Representative)	(DOB)
My Child(ren):
(Specify Name(s) of Children)	(DOB)	(Specify Name(s) of Children)	(DOB)
To:
Children's Division
Other Party
(Specify who will receive information requested)
I understand certain restrictions apply to release of this information, in accordance with state and federal laws. I understand I am not entitled to information regarding the identity of a reporter of abuse and neglect. I understand portions of the record to which I am not legally entitled will be redacted, in accordance with state and federal laws.
This authorization will expire on	or 90 days from the date of the signature below, if not
specified.	(Specify Date)
In signing below and providing my social security number as a personal identifier, I am affirming that I am legally authorized to request this release of information.
(Print Name)	(Social Security Number)	(DCN, if available)
(Signature)	(Date)