Doctor/psychiatrist: Name Yes No
Circuit Court of: blanks Yes No
Judge: blanks Type option 1 Type option 2
Division of Parole and Probation at: blanks Type option 1 Type option 2
Other: blanks Type option 1 NoType option 2
I also authorize the intended recipient to re-disclose and/or use all or part of the information obtained for purposes of blanks. I understand that the protected information herein may only be re-disclosed to those persons or entities specifically designated herein without further protection under HIPAA, Maryland statutes and federal confidentiality regulations for alcohol and substance abuse under 42 C.F.R. Part 2.