Youth and Family Forms

PerformCare uses forms for a variety ofdifferent purposes. Some are legally required by law in order to ensure we are protectingprotect the privacy of your a youth’s treatment information,. Some are  while others help designed to make it easier for you to request something from ussubmit requests (such as a record releases). Forms that are frequently accessed used by youth and families are made available here with helpful descriptions as appropriate.

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

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.

• Personal representative request form (PDF)
  • Personal representative request form FAQ (PDF)
• Formulario de solicitud de representante personal (PDF)
  • Formulario de solicitud para representante personal:  Preguntas frecuentes (PDF)

Consent to Release Alcohol/Drug Information Form

Substance use treatment services

In order to register a youth who needs substance use treatment or authorize care, the youth must sign this consent form. All associated service providers must be included on the form. Please have both the consent and the explanation available for the youth to view. If you are filling out the form without the provider present, please call PerformCare to ensure you have included all appropriate service providers.

• Consent to release alcohol/drug information (PDF)
  • Consentimiento para divulgar información confidencial sobre abuso de alcohol y drogas y otra información médica protegida (PDF)
• Explanation of consent form for alcohol/drug information (PDF)
• List of participating substance use treatment providers (PDF)