Youth and Family Forms
PerformCare uses forms for a variety of purposes. Some are required by law in order to ensure we are protecting the privacy of your treatment information. Some are designed to make it easier for you to request something from us (such as a record release). Forms that are frequently accessed by youth and families are made available here with descriptions as appropriate.
Sharing Health Information (HIPAA)
To request the release of a child's protected health information (either a physical or verbal release) from PerformCare, please use the form linked below.
If you are requesting that the information be released directly to you, enter your own information in Section B (Recipient Information) on page 1 of this form.
Please note that this form should be completed in its entirety. You should enter the youth's CYBER ID number where it asks for Member ID.
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 should be mailed to the following address:
Consent Processing Center
P.O. Box 7092
London, KY 40742-7092
| Language | Links |
|---|---|
| English | Authorization for Sharing Health Information (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) |
| 한국어 (Korean) |
건강 정보 공개 승인서 (PDF) |
| ગુજરાતી (Gujarati) |
આરોગ્ય માહિતી શેર કરવા માટે અધિકૃતતા (PDF) |
Personal representative form
This form allows another person to make health care decisions for a PerformCare member. This person must have legal authority to act on your 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 — FAQs (PDF)
- Formulario de solicitud de representante personal (PDF)
- Formulario de solicitud para representante personal — Preguntas frecuentes (PDF)
Intellectual/developmental disability services
- Apply for determination of eligibility for DD/ID services
- View summer camp forms and application process
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)
- Authorization for Sharing Health Information (PDF)
- Frequently Asked Questions — Authorization for Disclosure of Health Information (PDF)
- List of participating substance use treatment providers (PDF)