Form Prob Lib - Authorization To Release Confidential Information Drug Abuse Programs

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V PROB l IB
( Re v . 5 / 0 3 )
U NI TED STA TE S PR O BA TI O N SY STEM
A UT H O R I ZATI O N TO R ELE A SE C O N FI D EN TI A L I N FO R M A TI O N
D R UG M USE PR O G R A M S
t he unders i gned,
( Na me o f Cl i e nt )
he r eby a ut hor i ze
-
t o r el eas e conf i dent i al
t Name o f Pr o gr a m)
i nf or m a t i on i n i t s r ecor ds , pos ses s i on, or u owl edge, of what ever nat ur e m ay now exi s t or com e t o exi s t t o t he Uni t ed
St at es Pr obat i on O f f i ce of t he
D i s t r i ct of
t Na me o f Cou r t )
A r ans as
.
( St a t e )
The conf i de nt i al i nf or mat i on t o be r el eased wi l l i ncl ude: dat e of ent r ance t o pr ogr am ; a t t endance r ecor ds; t l ri ne
t e s t i ng r e s ul t s ; t y pe , f r e qu e nc y a nd e f f e c t i v e n es s of t he r a py; ge ne r a l a d j u s t me n t t o p r o gr a m nz l e s ; t ype a nd d os ag e of
me di c a t i o n; r e s pons e t o te a t me nt ; t e s t r e s u l t s ( ps yc hol ogi c a l , vo c a t i ona l , e t c . ) ; da t e o f a n d r e a s on f o r wi t hd r a wa l f r o m
pr op a m ; a nd pr or os i s .
The i nf or m at i on w hi ch I now aut hor i ze f or r el eas e i s t o be used i n cor mect i on wi t h m y part i ci pat i on i n t he af or e-
ment i oned pr ogr a m whi ch has been m ade a condi t i on of my
- -
( p r e t r i a l r e l e a s e , po s t - t l i a l r e l e a s e, p r ob a t i o n, or pa r o l e ) .
l unde rs t and t hat t he pr oba t i on of f i ce m ay us e t he i nf or mat i on her e by obt ai ned onl y i n cor mect i on wi t h i t s of f i ci al
dut i es, i ncl udi ng t ot al or par t i al di s cl os ur e of s uch, t o t he Di s t r i ct Court a nd/ or Uni t ed St at es Pa r ol e Comm i s si on when
ne ces sa r y f or t he pup os e of di s cha r gi ng i t s s upervi s or y dut i es ove r m e.
I under s t a nd t hat t hi s aut hor i za t i on i s val i d unt i l m y r el eas e f r om supe rvi s i on, at w hi ch t i m e t hi s a ut hori z at i on t o
us e or di s cl os e t hi s i nf or m at i on expi r es. I unde r st a nd t hat i nf or m a t i on used or di s cl os ed pur s uant t o t hi s aut hor i zat i on m a y
be di s cl osed by t he r eci pi ent and may no l onger be pr ot ect ed by f eder al or s t at e l a w .
I t mder s t and t ha t 1 have t he r i ght t o r evoke t hi s aut hor i z at i on, i n m i t i ng, at a ny t i m e by s endi ng s uch wri t t e n
not i f i cat i on t o t he pr ogr am ' s pr i vac y cont act a t :
t Na me a nd Ad dr e s s o f Pr og r a m)
I under s t and t hat i f I r evoke t hi s aut hori zat i on t o r el eas e conf i dent i al i nf or m at i on, I w i l l t her eby r evoke m y
aut hor i za t i on t o f urt her di s cl os ur e of s uc h i nf or m a t i on. 1 al so t mde rs t and t ha t r evoki ng t hi s aut hor i zat i on bef or e I s at i s f y
t he condi t i on of m y supe rvi s i on t hat r equi r es me t o par t i ci pat e i n t he pr ogr a m wi l l be r e por t ed t o t he cour t M y r evocat i on
of a ut hor i zat i on under s uch ci r cumst a nces coul d be consi der ed a vi ol at i on of a condi t i on of my pos t - convi ct i on s upe rvi si on.
( Si gna t u r e of Pa r e n t or Gu a r di a n i f Cl i e nt i s a M i no r )
( Si gna t ur e of Cl i e n t )
( Da t e Si gne d)
( Dat e Si gn e d)
( Na me & Ti t l e of W i t n e s s )
( Da t e Si g ne d )

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