Work Release Intake Form (Page 4 of 4) in pdf

DAKOTA COUNTY COMMUNITY CORRECTIONS - CONSENT FOR RELEASE OF INFORMATION

I, ________________________________(client), (DOB:___________), authorize Dakota County Community Corrections (DCCC) to:

Disclose to

Obtain from

Disclose, obtain, and exchange with the following individual(s) or entity (ies): _________________________________________

The following information about me listed below:



the dates of admission/anticipated discharge;



the attendance history and concerns;



the type of service (counseling, CD treatment, etc.);



the quarterly Progress Reports;



the Discharge Summary upon completion; and



the type of termination (satisfactory/unsatisfactory) for:

Chemical dependency/psychological or domestic abuse treatment records and evaluation

Medical history

Treatment information

Treatment discharge summary

Ongoing/Updated Reports

Other: Employment/contractors and/or education verification, treatment status and pertinent details

This information is needed to help DCCC provide efficient and successful supervision of me. I understand that I may authorize the

release of all, some, or none of the above-mentioned information but if I fail to release the information it may have a negative effect

on my probation status. I understand that I do not have to sign this Consent in order to receive health care benefits (treatment,

payment, enrollment or eligibility) except for health care services necessary to create any assessment or report for disclosure to

DCCC necessary for my conditions of probation/parole/supervision.

I understand what information about me will be disclosed or obtained from the above-mentioned individuals(s) or entities. I

understand that DCCC may have records about me that it received from other organizations and that if these records have been

used by DCCC and are filed in the records DCCC maintains about me and are of the type authorized to be released, these records

may be released with the DCCC records.

I understand that my records are protected under State and Federal privacy laws and that these records cannot be disclosed without

my written consent, unless otherwise authorized by law. I understand and consent to the re-disclosure by DCCC of the information

used or disclosed by this Consent and understand that it will no longer be protected by Federal privacy laws prohibiting re-

disclosure. I understand that DCCC cannot prevent re-disclosure of my information by the person/organization who receives my

records under this Consent, and that the information may not be covered by state and federal privacy protections after it is released.

By signing this Consent, I release DCCC from any and all liability resulting from a re-disclosure by the recipient.

I understand that I may revoke this consent in writing at any time; however, revocation will not pertain to data released or obtained

prior to the County’s receipt of my written revocation notice at one of the addresses listed below. Unless I revoke my consent

sooner, my permission to allow the release of information about me will automatically expire one (1) year from the date I sign this

release or when my probation ends, if sooner.

Client Signature

Date

Parent/Guardian Signature if client is under

Date

18 or under legal guardianship

Please forward to:

(Name/Title)

Judicial Center

Western Service Center

Northern Service Center

1560 Highway 55

14955 Galaxie Avenue

1 Mendota Road West, Ste 510

Hastings, MN 55033

Apple Valley, MN 55124

West St. Paul, MN 55118

Fax: (651) 438-8340

Fax: (952) 891-7282

Fax: (651) 554-6070

Tel: (651) 438-8288

Tel: (952) 891-7200

Tel: (651) 554-6060

3006A Release of Information (Consent)

Revised 10/10/13

Work Release Intake Form Page 4

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