| Requestor Name: | _______________________________________ |
| (Your Name/Provider Name) | _______________________________________ |
| Address: | _______________________________________ |
| _______________________________________ | |
| Phone Number: | _______________________________________ |
| E-mail address: | _______________________________________ |
I understand that the use or disclosure of confidential client information is prohibited except for the administration of programs providing public assistance to the client and I am aware of the penalties for unlawful use or disclosure as provided in 53-2-105 and 53-2-106, MCA.
I hereby certify that I am entitled to the confidential client information to which I am requesting access. I will not release the confidential information to others unless it is for purposes directly connected to the administration of the program for whose purpose it was originally provided. Further release of this information may only be done upon authorization by the client whose privacy interest is involved or it may be released to others if specifically permitted by law. I understand that a violation of this policy will subject me to disciplinary action, which may include termination of my contract with DPHHS.
I agree to indemnify and hold the Department of Public Health and Human Services harmless for all claims and damages arising from improper or illegal use or release of confidential information about DPHHS clients by me.
| Print name of individual making this request: | ________________________________ | Title: | _______________________ |
| Signature of individual requesting access: | ________________________________ | Date: | _______________________ |
| Mail To: | |
| CPIS Access Request Unit Tanya Little, CFSD Security Officer Montana Department of Public Health and Human Services P.O. Box 8005 Helena, MT 59604 |
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| Fax To: | |
| (406) 841-2487 |
If you have questions about the form or the system, call (406) 841-2429 or fax to (406) 841-2487
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