AUTHORIZATION FOR RELEASE OF CONFIDENTIAL RECORDS

I,   Name*   hereby authorize Jackson-Bibby Awareness Group to disclose information and records pertaining to my participation in the program to the following:

• The Department of Motor Vehicles.
• The Department of Healthcare Services.
• The County Offices of Alcohol and Drug Abuse Services.
• The appropriate branches of the Judicial System.
• My personal attorney.
• My personal physician.

The disclosure of information and/or records herein authorized is required for the purpose of establishing or determining my status, progress, and/or compliance with the terms and conditions of my participation in the program. Such disclosure shall be limited to information and/or records in regard to my progress and participation in the program.

I understand that this authorization can be revoked by the undersigned at any time except to the extent that action has been taken in reliance thereon. If not earlier revoked, it shall terminate ninety (90) days after my participation in the program has ended. I also understand that despite the codes (California Civil Codes 56.11 and 56.15, and Federal Regulation CFR Section 2.31), confidential information and/or records may be disclosed without my authorization pursuant to state and federal law in the following circumstances:

• Pursuant to a proper subpoena or court order.
• Reporting child abuse or elder abuse.
• Reporting an individual who is a danger to him/herself or a third party.
• Reporting the intent to commit a crime on program premises or against program staff.

A photocopy, facsimile or duplicate copy of this authorization shall be as valid as the original.

I, * also hereby authorize Jackson-Bibby Awareness Group , to disclose information to my designated representative: