Release of Information

CONFIDENTIAL INFORMATION RELEASE AUTHORIZATION

Completion of this form authorizes the release of information described in the section below called “Specific Description of Records Authorized for Release”. The person (record subject) whose records are released may have a right to inspect and, upon paying any applicable fees, obtain a copy of the disclosed records. Except for medication/somatic treatment records, a director/designee of a treatment facility for mental illness, developmental disability, alcohol or drug abuse may deny that right during treatment in some circumstances. Section 51.30, Wis. Stats., DHS 92.03-92.06 Wis. Adm. Code.
Agency/Organization I Authorize to Release Information

Hope Council on Alcohol & Other Drug Abuse, Inc. | 6103 39th Ave. Kenosha, WI 53142 Phone: (262) 658-8166 | Fax: (262) 658-8210 | Email: info@hopecouncil.org
Your Information

Person whose records will be released. (Record Subject)
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
SSN (Last 4 Digits ONLY)
Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Agency or Organization

Your information may be released to or received from this entity.
Name
Enter the agency name if you do not know the direct parties name.
Agency / Organization Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Specific Description of Records Authorized for Release
- Assessment Summary
- Progress
- UA/Breathalyzer results
- Progress Notes
- Attendance
- Participation
- Treatment Plan
- Collateral Information
- Findings
- Discharge Summary
- Abstinence
- Alcohol/Other Drug Test Results
- Substance Abuse History
- Psychiatric & Psychological testing results
- Supervised Visitation Records
Purpose or Need for Release of Information:

The purpose of this release is to aid in determining compliance with the court and/or Wisconsin Department of Transportation orders.

By signing this document, I also consent to disclosure of the specific information listed in this release by the agency listed above to Hope Council on Alcohol & Other Drug Abuse, Inc.
Understandings:

This authorization is voluntary. Refusal to sign will not affect treatment, payment, enrollment or benefits eligibility except for clients seeking county funding will not be eligible without signing.

The information that I authorize to be released may be redisclosed by the recipient of the records only if allowed by law. If information is redisclosed, the recipient of the redisclosed information may be controlled by different laws.

I may revoke this authorization, in writing, at any time except for information already released as a result of this authorization. The written revocation must be given to the agency/organization I authorized to release information.

Unless revoked, this authorization will remain in effect until the authorization expires 16 months(s) from the date I sign this authorization.
Upload a copy of a valid Drivers License or State/Federal (passport) ID card:

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As evidenced by my signature, I hereby authorize disclosure of records to the person(s) or agency(s) specified above.
Date

MonthDayYear
Date
Signature
Should be Empty:

CONFIDENTIAL INFORMATION RELEASE AUTHORIZATION

Agency/Organization I Authorize to Release Information

Your Information

Agency or Organization

Specific Description of Records Authorized for Release

Purpose or Need for Release of Information:

Understandings:

As evidenced by my signature, I hereby authorize disclosure of records to the person(s) or agency(s) specified above.