General Release

NOBLE COUNTY PROBATION/COMMUNITY CORRECTIONS ROOM 110 COURTHOUSE 101 N. ORANGE ST.

ALBION, IN.46701 TELEPHONE: (260) 636-3116

General Consent for Release of Confidential Information

Name*

Full Name

Date of Birth*

Date

hereby consents to reciprocal unrestricted communication between Noble County Probation/Community Corrections and the following:

Noble County Jail Medical StaffDepartment of Child Services

*1. Name*

Full Name of person or agency you want to have access to your information regarding your supervision or treatment. N/A if no one

Phone*

*2. Name

Full Name of person or agency you want to have access to your information regarding your supervision or treatment. N/A if no one

Phone

*3. Name

Full Name of person or agency you want to have access to your information regarding your supervision or treatment. N/A if no one

Phone

*4. Name

Full Name of person or agency you want to have access to your information regarding your supervision or treatment. N/A if no one

Phone

The purpose and need for disclosure is to provide collaboration with the above entities regarding my attendance, progress, and attitude toward my evaluation and required treatment, education or both. The extent of necessary information to be disclosed includes:

1. Attendance 6. Completion

2. Prognosis 7. Educational Records

3. Results of Drug Scren 8. Discharge Plan/Completion Letter

4. Diagnosis/Assessment 9. Medical Records

5. Required Services

I understand that I may revoke this consent at any time in writing, except where there has been action taken in reliance upon this release. Otherwise this consent will remain in effect until there has been a formal and effective termination of my involvement with the Noble County Probation/Community Corrections, such as the discontinuation of all court supervision upon my successful completion of all requirements OR upon sentencing for violation of the terms of my supervision.

I understand that any disclosure made between the above-named agencies or individuals is bound by 42 CFR 2, which is the Code of Federal Regulations governing confidentiality of substance abuse patient records, and that recipients of this information may re-disclose it only in connection with their official duties. I have received a copy of this signed form.

(Client Signature)*

Date*

Date

Supervising Officer's Name*

Witness

(A facsimile copy of this completed form shall be as valid as the original) All blank lines must be filled in or crossed out at the time of signing.