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Authorization To Release Information To Probation Officer - Private Person Or Organization PROB 11G - Missouri
| Authorization To Release Information To Probation Officer - Private Person Or Organization Form. This is a Missouri form and can be used in Eastern District US Probation Office Federal . |
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OPROB 11G (Rev. 5/03) AUTHORI ZAT ION TO RELEA SE INFORMATION (PRIVATE PERSON OR ORGANIZATION) TO PROBATION OFFICER TO WHOM IT MAY CONCERN: I, , the undersigned, hereby authorize the United States Probation Office for the District of ,or its authorized representative(s) or employee(s), bearing this release or copy thereof, to obtain any information in your files pertaining to my: Employment Education Records (including, but not limited to academic achievement, attendance, athletic, personal history, and disciplinary records) Medical Records Psychological and Psychiatric Records I hereby direct you to release such information upon request of the bearer. This release is executed with full knowledge and understanding that the information is for the United States Probation Offices official use. I hereby release you, as custodian of such records, any school, college, or university, or other educational institution; hospital or other repository of medical records; social service agency; any employer or retail business establishment, including its officers, employees, or related personnel, both individually and collectively, from any and all liability for damages of whatever kind which may at any time result to me, my heirs, family, or associates because of compliance with this authorization and request for information or any other attempt to comply with it. Regarding protected health information, I understand that this authorization is valid until my release from supervision, at which time this authorization to use or disclose this information expires. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Regarding protected health information, I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to the programs privacy contact at: . (Name and Address of Program) Regarding protected health information, I understand that if I revoke this authorization to release confidential information, I will thereby revoke my authorization to further disclosure of such information. I also understand that revoking this authorization before I satisfy the condition of my supervision that requires me to participate in the program will be reported to the court. My revocation of authorization under such circumstances could be considered a violation of a condition of my post-conviction supervision. (Authorizing Signature - Full Name) (Full Name - Printed or Typed) (Date) WITNESS (Probation Officer) (Date)
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