This authorization is for any facility/hospital/organization your Public Defender determines necessary to effectively represent you and your interests. That Public Defender will still notify you of any requests sent.

This form is set to provide maximum discretion to the Public Defender and their investigators, if any of the potential places/items make you uncomfortable or concerned, please reach out to them before proceeding.

I authorize:

[The facility/hospital/organization] to make available for inspection, to the Office of the State Public Defender, the following information now in your [facility/hospital/organization's] possession or control

OR

[The facility/hospital/organization] to disclose and give copies to the Office of the State Public Defender, the following information now in your [facility/hospital/organization's] possession or control and to answer any questions that may be asked regarding this information.

This authorization covers the approximate time period from [at directive of Public Defender] - to [at directive of Public Defender].

This authorization may include:

• psychotherapy Notes
• specific medical treatment record(s)
  • history and physical
  • admission/intake form
  • operative reports
  • treatment/progress notes
  • laboratory reports/studies
  • radiographs/MRI’s/imaging studies
  • physician’s orders
  • nursing notes
  • medications sheets
  • discharge summary/orders
  • HIV/AIDS diagnosis/treatment records
  • other ALL information in file
• specific mental health treatment record(s) requested
  • history & physical
  • education assessment
  • psychological testing
  • diagnosis/assessment
  • progress/treatment notes
  • observation report
  • competency/sanity evaluations
  • physicians orders
  • medication sheets
  • discharge summary/orders
  • other ALL information in file
• specific confidential drug and alcohol treatment information requested
  • substance abuse evaluation
  • discharge summary/orders
  • progress/treatment notes
  • diagnosis or testing instrument
  • other ALL information in file
• Colorado Dept. of Corrections records

The requested information may not be protected from re-disclosure by the Offce of the State Public Defender: however; if this information is protected by the Federal Substance Abuse Confidentiality Regulations (42 C.F.R. part 2 the Office of the State Public Defender may not re-disclose such information without my further written authorization unless otherwise provided for by state or federal law.

I may refuse to sign this authorization and that my refusal will not result in the termination of my representation or ability to obtain treatment services, or affect my elgibility for benefits.

I may have a copy of this authorization.

The purpose of this disclosure is: legal purposes.

This Consent expires: One year from the date of signing.

I have read this authorization and by signing acknowledge that knowingly and freely consent to the disclosure of this information.