Michigan > Statewide > Criminal > Misdemeanor

Waiver Of Privilege Against Disclosure (Alcohol Or Substance Abuse Treatment) DC 214 - Michigan

Waiver Of Privilege Against Disclosure (Alcohol Or Substance Abuse Treatment) Form. This is a Michigan form and can be used in Misdemeanor Criminal Statewide .
 Fillable pdf Last Modified 2/10/2005
Get this form for FREE as a print-only pdf

Approved, SCAO STATE OF MICHIGAN CASE NO. WAIVER OF PRIVILEGE JUDICIAL DISTRICT AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment) Court address Court telephone no. Defendant name and address The State of Michigan THE PEOPLE OF v Program name: Director or designee: Release to: District Court I, the defendant in this case, waive my privilege against disclosure regarding alcohol/substsance abuse treatment and authorize theabove program, its director or designee to release any and all information and records concerning my attendance, progress, servicesreceived, counseling reports, conduct appraisals, and recommendations for additional services to the district court listed above forthe purpose of assisting the court in an appropriate disposition of this case. This authorization will remain in effect until the purpose for which it was given no longer exists. Date Defendants signature Witness DC 214 (11/83) WAIVER OF PRIVILEGE AGAINST DISCLOSURE (Alcohol/Substance Abuse Treatment)
Link/Embed this Document

Popular Searches

  1. Decree of Dissolution of Marriage
  2. proof of service of summons
  3. fee waiver
  4. Petition to Expunge
  5. Income and Expense Declaration
  6. Notice and Acknowledgment of Receipt
  7. writ of replevin
  8. proof of claim
  9. divorce forms
  10. abstract of judgment

Bookmark and Share