Oasas Consent To Release Of Information printable pdf download

NEW YORK STATE

OFFICE OF ALCOHOLISM AND SUBSTANCE ABUSE SERVICES

Client’s Last Name

First

CONSENT TO RELEASE OF INFORMATION

CONCERNING

CHEMICAL DEPENDENCE TREATMENT

FOR CRIMINAL JUSTICE CLIENTS

Client’s New York State Identification Number (NYSID)

□ □ □ □ □ □ □ □ □

Referring Entity’s Staff Member’s Name:

___________________________________________

Referring Entity’s Name & Address

Referring Entity Type

[ ] Parole - General

[ ] District Attorney

[ ] Parole - Release Shock

[ ] Court

[ ] Parole - Release Willard

[ ] Probation

[ ] Parole - Release Resentence

_____________________________________________

1) SEND A COPY OF THIS COMPLETED FORM TO THE CLIENT’S TREATMENT PROVIDER;

INSTRUCTIONS:

2) ADD A COPY OF THIS COMPLETED FORM TO THE CLIENT’S CRIMINAL JUSTICE FILE; AND

3) PROVIDE A COPY OF THIS COMPLETED FORM TO THE CLIENT/DEFENDANT

1) I, the undersigned, Client/Defendant, hereby CONSENT and authorize communication between the above named Referring

Entity, my Chemical Dependence Treatment Provider: __________________________________________________________ ____

and the following: ____________________________________________________________________________________________

________________________________________________________________________________________________________________________

I CONSENT to DISCLOSURE OF INFORMATION concerning my current and past individual assessment or evaluation, intake

summary, diagnosis, treatment recommendation, date of admission, and status as a patient including course and level of treatment (i.e.

residential, community based, individual, or group), my progress and compliance including but not limited to: my attendance or lack of

attendance at treatment, dates and results of toxicology/urinalysis, cooperation with my treatment program, prognosis, treatment

completion or reason(s) for termination, date of discharge, discharge status, and discharge plan.

Such disclosure is for the PURPOSE of enabling the entities listed above to communicate as to my treatment needs, activities,

history and attitude towards my evaluation and treatment for purposes of monitoring the terms and conditions of treatment, release,

case management purposes, and for carrying out other official duties; AND

2) I further CONSENT and authorize communication between and among the above named Referring Entity and the New York

State Office of Alcoholism and Substance Abuse Services (OASAS); and OASAS to DISCLOSE INFORMATION to the New York

State Division of Criminal Justice Services (DCJS), concerning admission and discharge data for the PURPOSE of research and

program evaluation activities. I understand that any reports or studies compiled from my records disclosed pursuant to this release will

not include personally identifiable information which will remain confidential and protected from further re-disclosure.

I, the undersigned, have read the above and authorize the staff of the above named disclosing entities to disclose, obtain and share

such information as herein specified. I understand that, unless otherwise specified, this consent will remain in effect and cannot be

revoked by me until there has been a formal and effective termination or revocation of my release from confinement, interim probation

supervision, probation, parole, post-release supervision, or local conditional release or other proceeding or determination by a releasing

authority under which I was referred to or otherwise agreed to treatment.

I also understand that any disclosure of any identifying information is bound by Title 42 of the Code of Federal Regulations 42 CFR Part

2, governing the confidentiality of alcohol and drug abuse patient records, as well as the Health Insurance Portability and Accountability

Act of 1996 (HIPAA) 45 C.F.R. Pts. 160 &164; and that redisclosure of such information to a party other than those designated above is

forbidden without additional written authorization on my part.

Any information released through this form MUST be accompanied by the form Prohibition on

NOTE:

Redisclosure of Information Concerning Chemical Dependence Treatment Patient (TRS-1)

I understand that generally the program may not condition my treatment on whether I sign a consent form, but that in certain limited

circumstances I may be denied treatment if I do not sign a consent form. I have received a copy of this form, as recognized by my

signature below.

(Print Name of Client)

(Signature of Client)

(Date)

TRS-49 (09/23/09)

Oasas Consent To Release Of Information

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