DOEP Release of Information

AUTHORIZATION FOR THE RELEASE OF INFORMATION
I hereby authorize Access 2 Recovery to release information from the records concerning:*

First NameLast Name
Release Information to:

Kaufman County CSCDPerson or Entity
Person or Entity
Relation to You
Address: Street Address Address Line 2 City State Zip
Phone Number: Area Code Phone Number
Entity:
408 E College Street Terrell, Texas 75160
(469) 376-4700
I understand that such disclosure will be limited to the following specific types of information:

1.       Information concerning general progress while in Access 2 Recovery programs;

2.       Counselor’s reports of attendance, participation and prognosis;

3.       Information contained in written records submitted by myself;

4.       General demographic and academic information;

5.       Indications of active alcohol or other drug use;

6.       Admission and discharge dates including associated reports

7.       Other:___________________________________________________________

I understand this consent will remain in effect for two (2) years from the date of signature below.
Signature*

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Date
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AUTHORIZATION FOR THE RELEASE OF INFORMATION