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Consent For Disclosure Of Confidential Substance Abuse Information - Oregon

Consent For Disclosure Of Confidential Substance Abuse Information Form. This is a Oregon form and can be used in Drug Court Circuit Court Malheur Local County .
 Fillable pdf Last Modified 5/4/2005
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MALH EUR COUNTY CIRCUIT COURT S.A.F.E. COURT PROGRAM Malheur County Courthouse 251 B Street West - Vale, OR 97918 541/473-5533 CONSENT FOR DISCLOSURE OF CONFIDENTIAL SUBSTANCE ABUSE INFORMATION: S.A.F.E. Court REFERRAL I, ______________________________________, hereby consent to communication between Lifeways Behavioral Health, Circuit Court Judges, Malheur County District Attorney,Defense Attorney, Malheur County Community Corrections, Training and EmploymentConsortium, the participants employers (present and future), the Department of HumanServices, Malheur County Justice Courts, and the S.A.F.E. Court Coordinator. The purpose of and need for this disclosure is to inform the court and other above-namedparties of my eligibility and/or acceptability for substance abuse treatment services and mytreatment attendance, prognosis, compliance, and progress in accordance with the S.A.F.E. Courtmonitoring criteria. Disclosure of this confidential information may be made only as necessary for andpertinent to hearings and/or reports concerning charges and case numbers. I understand that this consent will remain in effect and cannot be revoked by me untilthere has been a formal and effective termination of my involvement with the S.A.F.E. Court forthe case named above, such as the discontinuation of all court and/or probation supervision uponmy successful completion of the S.A.F.E. Court requirements or upon sentencing for violatingthe terms of my S.A.F.E. Court involvement and/or probation. I understand that any disclosure made is bound by Part 2 of Title 42 of the Code ofFederal Regulations, which governs the confidentiality of substance abuse patient (or client)records, and that recipients of this information may re-disclose it only in connection with theirofficial duties. Dated ________ day of _____________________________, 20_____. ___________________________________ DefendantConsent for Disclosure of Confidential Substance Abuse Information: S.A.F.E. Court Referral (7/25/2002)
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