Consent For Release-Disclosure Of Confidential Information {CCCR 0108}

CCCR 0108 - CONSENT FOR RELEASE/DISCLOSURE OF CONFIDENTIAL INFORMATION. The form authorizes various parties, including the Presiding Judge, team members of the Program, representatives of the Cook County Adult Probation Department, Cook County State's Attorney's Office, Cook County Public Defender's Office, Substance Use Disorder Treatment Providers, Treatment Alternatives for Safe Communities, Presence Health System, any Veterans Health Administration (VHA) hospital or treatment facility or other service provider referred to during participation in the program, representatives of the Cook County Sheriff, or any law enforcement team member, representatives of the Chief Judge's Office, and any other person permitted by the Presiding Judge to attend team staffing(s) for training and educational purposes to communicate with and disclose to one another information concerning the following: Any evaluation, diagnosis, prognosis, hospitalization, treatment, urinalysis result (including disclosure of test results in open court) or other information concerning my attendance, progress and compliance with treatment, substance use disorders, or otherwise related to my health or treatment. The purpose of the disclosure is to inform the court and other named person(s) listed above of my eligibility for treatment and my compliance and progress in treatment pursuant to the conditions of my court ordered participation in treatment. www.FormsWorkflow.com