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Consent To Release Confidential Information

ADAPT

CONSENT TO RELEASE CONFIDENTIAL INFORMATION

I________________________________________hereby consent to communication between ADAPT and

referral agency. The communication is a condition of:

CPS

Court Sentencing

Parole

Pre-trial Sentencing

Probation

The purpose of this consent is to provide the recipient with information about my attendance and

progress in treatment which may affect my status with the Criminal Justice System. The following information

may be released:

I understand that this consent will remain in effect until:

I also understand that the recipient may use this information only in connection with official duties regarding my

criminal justice status and may not make it available for general investigations or other unrelated purposes.

Further, this information can be re-disclosed and used only to carry out the person's official duties with regard to

the court action. I understand that my signature below will not have effect on the ability or inability to determine,

limit or restrict my treatment.

CLIENT’S SIGNATURE

DATE

STAFF SIGNATURE

DATE

Confidentiality Prohibition on Re-disclosure: This information has been disclosed to you from records whose confidentiality is

protected by Federal Law. Federal regulations (42 CFR Part II and 45 CFR HIPAA) prohibit you from making any further disclosure of it

without the specific written consent of the person to whom it pertains, or as otherwise permitted by such regulations. A general

authorization for the release of medical or other information is not sufficient for this purpose. The Federal rules restrict any use of

the information to criminally investigate or prosecute any alcohol or drug abuse client.

01/2012

Consent To Release Confidential Information