Client Authorization For Disclosure of Information
Probation and Parole ROI
Client Name
First Name
Last Name
Client Date of Birth
-
Month
-
Day
Year
Date
Today's Date
Social security number
I authorize the Kentucky Department Of Drug and Alcohol to (check all that apply)
RELEASE information concerning services to the above individual
OBTAIN information concerning services to the above individual
Sending Party
Receiving Party
Information to be disclosed is (check all that apply)
Dates of Treatment
Participation in Program
Progress
Discharge Summary
Clinical Records
Treatment Plan
Assessment and Recommendations
Date and Type of Discharge
Medical Records and Drug Screens
Purpose or needs for such disclosure is to (check all that apply)
Inform the referring person or agency of my status, condition progress
Fulfill condition of probation parole or court order
Obtain information for assessment
Verify medical treatment and inform physician of program participation
Medical Records and Drug Screens
Coordinate treatment
Discuss conditions with family/friends
Facilitate referral
Other
This authorization expires at the end of treatment affiliation with the Community Services Substance Abuse Program, and may be revoked at any time except when the disclosing agency has already taken action in reliance on it.
This information has been disclosed to you from records whose confidentiality is protected by Federal Law. Federal Regulation (42 C.F.R. part 2) prohibit you from making any further disclosure of this information without specific written consent of the person to whom it pertains or as otherwise permitted by C.F.R. Part 2. The criminally investigate and prosecute any alcohol or drug abuse patient. (52FR21809, June 9, 1987 52FR41997, Nov 2, 1987) HIPPA Compliance confidentiality statement: This communication contains information that is confidential. It is for the exclusive use of the intended recipient(s). If you are not the intended recipient(s) please note that any form of distribution, copying, forwarding, or use of this communication or the information therein is strictly prohibited and may be unlawful. If you have received this communication in error, please return it to sender.
I have read or been informed that all blanks are properly filled in prior to my signature, and I understand that this form is not required as a condition of treatment. I hereby release to you, your organization, or others from liability or damage, which may result from furnishing the information requested above.
*
Client Signature
This document was read in its entirety and reviewed thoroughly with above named client who granted verbal permission to sign this agreement on his/her behalf.
Agree
Disagree
*
Witness Signature
Submit
Submit
Should be Empty: