DOC AUTHORIZATION FOR RELEASE OF INFORMATION

do hereby consent to the disclosure by the Department of Corrections and/or Alcohol & Drug Services, Inc. to the Office of the Public Defender, any of the hereinafter described information which may be protected from disclosure by virtue of the provisions of federal regulations (42 C.F.R., Part 2, C.R.S. 1973, 27-10-120, and C.R.S. 1973, 24-72-202-4) for criminal justice purposes. The extent or nature of the information to be disclosed is as indicated below for the period of time incarcerated at the Department of Corrections.

1. Disciplinary Reports and Dispositions
2. Classification and Placement Decisions
3. Incident/Accident Reports
4. Program Completion Certificates or Notifications
5. Program Assessment Summaries (No Longer Prepared After 4/1/14)
6. Colorado Transitional Accountability Plan (CTAP) Records
7. Significant Medical Records
8. Significant Mental Health Status Reports
9. Drug and Alcohol History, Progress, and Attendance Data
10. Other [Items which my Public Defender determines necessary]

THIS CONSENT IS SUBJECT TO REVOCATION AT ANY TIME, BY MYSELF GIVING WRITTEN NOTICE TO THE DEPARTMENT OF CORRECTIONS AND/OR ANY OF THE ABOVE-LISTED AGENCIES; AND UNTIL SAID NOTICE IS GIVEN, THIS CONSENT DOES NOT EXPIRE UNTIL MY RELEASE FROM THE DEPARTMENT OF CORRECTIONS.

NOTICE TO RECIPIENT OF DRUG AND ALCOHOL RECORDS: This information has been disclosed to you from records whose confidentiality is protected by federal law. Federal regulations (42 C.F.R., Part 2) prohibit you from making any further disclosure of it without the specific written consent of the person to whom it pertains or as otherwise permitted by such regulations. A general authorization for the release of medical or other information is NOT sufficient for this purpose.

I understand that the information to be released may include AIDS/HIV infection documentation.

I have read the above and foregoing AUTHORIZATION FOR RELEASE OF INFORMATION, and I hereby acknowledge that I am familiar with and fully understand the terms and conditions of this consent.