Youth and Family Forms
PerformCare uses forms for different purposes. Some are legally required to protect the privacy of a youth’s treatment information, while others help make it easier for you to submit requests (such as record releases). Forms that are frequently used by youth and families are available here with helpful descriptions.
Authorization for Sharing Health Information Form (HIPAA Compliant)
To request the written or verbal release of a youth’s protected health information from PerformCare, please use the forms linked below.
If you are requesting that the information be released directly to you, enter your own information in Part B (Recipient) on page 1 of this form.
Please note that this form should be completed in its entirety. Incomplete or incorrect forms may delay the fulfillment of the request. If you have questions, you can call Member Services at 1-877-652-7624.
Completed forms can be emailed, faxed, or mailed to PerformCare:
- Email to Shared-PCNJHealthInfo@performcarenj.org.
- Fax to 1-877-736-9166.
- Mail to the following address:
PerformCare NJ
300 Horizon Drive
Suite 306
Robbinsville, NJ 08691
Authorization for Sharing Health Information Form
| Language | Links |
|---|---|
| English | Authorization for Sharing Health Information Form (PDF) Frequently Asked Questions — Authorization for Sharing Health Information (PDF) |
| Español (Spanish) | Autorización para compartir información médica (PDF) Formulario de Autorización de divulgación de información médica: Preguntas frecuentes (PDF) |
| Português (Portuguese) | Autorização para compartilhar informações médicas (PDF) |
| 中文（普通话） (Chinese (Mandarin)) | 健康信息分享授权 (PDF) |
| 中文（粵語） (Chinese (Cantonese)) | 健康資訊分享授權 (PDF) |
| 한국어 (Korean) | 건강 정보 공개 승인서 (PDF) |
| ગુજરાતી (Gujarati) | |
| عربي (Arabic) | (PDF) تصريح لمشاركة المعلومات الصحية |
| kreyòl ayisyen (Haitian Creole) | Otorizasyon pou pataje enfòmasyon sante (PDF) |
Personal Representative Request Form
This form (PDF) allows another person to make health care decisions for a youth. This person must have legal authority to act on the youth’s behalf. This includes legal guardianship or health care power of attorney.
Please note that on this form, you should enter the youth’s CYBER ID number where it asks for Member ID. If you have questions, you can call Member Services at 1-877-652-7624.
Substance Use Treatment Services
Before a youth can be registered for or authorized to receive substance use treatment, they must sign the Informed Consent Form for Sharing Protected Health and Substance Use Information. Include all associated service providers on the form. Please make both the consent form and the explanation available for the youth to review prior to signing. If you are completing the form without the provider present, call PerformCare to confirm that all appropriate service providers are included.