Treatment Court Release Of Information Form | Pdf Fpdf Doc Docx | Oregon

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Treatment Court Release Of Information Form | Pdf Fpdf Doc Docx | Oregon

Treatment Court Release Of Information Form

This is a Oregon form that can be used for Circuit Court within Local County, Jackson.

Alternate TextLast updated: 10/1/2014

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AUTHORIZATION FOR USE AND DISCLOSURE OF INFORMATION WITHIN TREATMENT COURT PROGRAMS Section A Legal Last Name First MI Date of Birth Other Names Used by Client/Applicant Case ID# By signing this form, I authorize the following record holder (circuit court, agency, or medical or other provider) to disclose the following specific confidential information about me: Section B Release From Specific Information to be Disclosed Mutual Exchange: Yes/No If the information contains any of the types of records or information listed below, additional laws relating to use and disclosure may apply. I understand that this information will not be disclosed unless I place my initials in the space next to the information: Alcohol/Drug diagnoses, treatment, or referral _______ Mental Health ______ Section C Release To (address required if mailed) If releasing to a staffing team, list staffing team members Purpose Expiration Date or Event* Eligibility and/or acceptability for substance abuse treatment services and my treatment attendance, prognosis, compliance, and progress in accordance with the drug treatment court programs' monitoring criteria. Identifying information that may include treatment status, where necessary, will be disclosed in the normal course of court proceedings open to the public, and I hereby authorize such disclosure. I can revoke this authorization at any time. The revocation will not affect any information that was already disclosed. I understand that state and federal law protects information about my case. I understand what this agreement means and I approve of the disclosures listed. I am signing this authorization of my own free will. I understand that the information used and disclosed as stated in this authorization may be subject to redisclosure and no longer protected under federal or state law. However, I also understand that federal or state law may restrict redisclosure of HIV/AIDS, mental health, and drug/alcohol diagnosis, treatment, or referral information. Section D Full Legal Signature of Individual or Authorized Personal Representative Full Legal Signature of Parent or Guardian- Required if Client is under 14 Name of Staff Person (print) Relationship to Client Relationship to Client Date Date Initiating Agency Name/Location Date *The authorization expires at separation from the program. Full Legal Signature of Agency Staff Person Making Copies Print Staff Name This is a true copy of the original Authorization document. See Important Information on Page 2 of this Form Page 1 of 2 American LegalNet, Inc. www.FormsWorkFlow.com Important Information for the Client This is a Voluntary Form. Your treatment provider may not condition treatment, payment, enrollment, or eligibility for the treatment provider's benefits on the provision of this authorization. Participation in this court program requires your authorization for the treatment program to provide necessary information for the court program. This authorization form is used to obtain information to assess compliance and progress toward achieving treatment court objectives in your case. Refusal to sign or a decision to revoke the authorization will result in termination from the treatment court program. Disclosure: This authorization for use and disclosure of information necessary to participate in the treatment court program. The information will be used by and disclosed to the people or programs listed on the authorization. The information disclosed pursuant to this authorization may no longer be protected by the HIPAA Privacy Rules. For example, the judge and attorneys who receive the information are not subject to the HIPAA Privacy Rules, and information disclosed in the normal course of court proceedings will no longer be protected by the HIPAA Privacy Rules. But the federal regulations about substance abuse treatment records will continue to apply to the information, the extent required by those regulations. Identifying information, where necessary, will be disclosed in the normal course of court proceedings open to the public, and I hereby authorize the same. Redisclosure: After you authorize a disclosure of your substance abuse treatment records, federal regulations (42 CFR Part 2) prohibit the recipient of those records from redisclosing those records unless further disclosure is expressly permitted by your written authorization or by other provisions of the federal regulations. Also, if your records are disclosed to a covered entity under the HIPAA Privacy Rules, the covered entity may only redisclose your records with your written authorization or by other provisions of the HIPAA Privacy Rules. State law prohibits further disclosure of HIV/AIDS information (ORS 433.045, OAR 333-12-0270); and state law prohibits further disclosure of mental health, substance abuse treatment, vocational rehabilitation and developmental disability treatment information from publicly-funded programs (ORS 179.505, ORS 344.600) without specific written or oral authorization. Revocation: Revocation will result in termination from the treatment court program. Using This Form 1. Terms Used: Mutual exchange: A "yes" allows information to go back and forth between the record holder and the people or programs listed on the authorization. Staffing Team: A number of individuals or agencies regularly working together. The agencies of which the staffing team members belong must be identified on this form. Assistance: When possible, your attorney should complete this form with you. Be sure you understand the form before signing. Feel free to ask questions about the form and what it allows. You may substitute a signature with making a mark or by asking an authorized person to sign on your behalf. Guardianship/Custody: If the person signing this form is a personal representative, such as a guardian, a copy of the legal documents that verify the representative's authority to sign the authorization must be attached to this form. Similarly, if an agency has custody, and their representative signs, their custody authority must be attached to this form. Revoke: If you later want to revoke this authorization, contact the treatment court program coordinator. Revocation can be oral or in writing. Federal regulations do not require that the revocation be in writing for Drug and Alcohol Programs. No more information will be disclosed or requested after the authorization is revoked, except to the extent that action has been taken in reliance

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