Legal Release of Information - Rev5.13.08
Uploaded by
Dawn FarmLegal Release of Information - Rev5.13.08
Uploaded by
Dawn FarmCRIMINAL JUSTICE CONSENT FOR THE RELEASE
OF CONFIDENTIAL INFORMATION:
I, , hereby consent to communication between:
Dawn Farm
P.O. Box 981098
Ypsilanti, MI 48150
(734) 485-8725
and
The purpose of and need for the communication and disclosure is to inform the criminal justice
agency(ies) listed above of my attendance and progress in treatment. The extent of information to be
disclosed is my treatment attendance, prognosis, compliance and progress in accordance with the
referring court’s monitoring criteria and
I understand that my alcohol and/or drug treatment records are protected under the federal regulations
governing Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and the Health
Insurance Portability and Accountability Act of 1996 (“HIPAA”), 45 C.F.R. Pts. 160 & 164. I also
understand that I may revoke this consent at any time except to the extent that action has been taken in
reliance on it, and that in any event this consent expires automatically as follows:
______ there has been a formal and effective termination or revocation of my release from
confinement, probation, or parole, or other proceeding under which I was mandated into
treatment, or
______
(Specify other time when consent can be revoked and/or expires)
I understand that I might be denied services if I refuse to consent to a disclosure for purposes of
treatment, payment, or health care operations, if permitted by state law. I will not be denied services if I
refuse to consent to a disclosure for other purposes.
