Request and Consent for Release of Confidential Information

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Idaho Department of Correction Protect the public, our staff and those within our custody and supervision BRAD LITTLE JOSH TEWALT Governor Director REQUEST AND CONSENT FOR RELEASE OF CONFIDENTIAL INFORMATION 1.Name, address and information of person authorizing release of records. Name:_________________________________ Phone:____________________ IDOC # (if applicable) ________________ Other names: ___________________________ Date of Birth: ______________ Social Security No: ___________________ Mailing Address: ______________________________________________________________________________________ 2.Statement of Request and Authorization I hereby request and authorize communication between the Idaho Department of Correction (IDOC), Division of Probation and Parole, and any entity contacted by IDOC, including:_______________________________________________________. The extent of information that may be disclosed, includes the following records and documentation (initial all that apply): ______ Evaluation/Assessments ______ Psychosexual Evaluation ______ Medications ______ Military ______ Counseling records ______ Treatment records ______ Mental Health records ______ Education ______ Child support ______ Employment ______ Social histories ______ Legal/Criminal/juvenile records ______ Social Security Administration ______ Problem Solving Court records ______ Other___________________ _______ Medical records: _______ Drug and alcohol treatment information, including: from _______ to _______ _____Whether I am enrolled _____ Diagnosis/prognosis and/or regarding ____________ _____ Cooperation level _____ Presence in a facility ___________________________ _____ Treatment/discharge plan _____ Attendance The information release is for the purpose(s) of (initial all that apply): _______ Court-ordered Presentence Investigation _______ Probation and/or Parole purposes I understand that the above records are protected under federal regulations including the Health Insurance Portability and Accountability of 199 (HIPAA), 45 C.F.R. Parts 160 & 164, and/or Confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2, and cannot be disclosed without my written consent unless otherwise provided for in these regulations. Recipients of this information may re-disclose the information only in connection with their official duties. I understand that this authorization is subject to revocation by me if provided in writing, except to the extent that disclosure has already occurred in reliance upon this authorization, and subject to the conditions explained below. I understand this information may be re-released in accordance with Idaho Criminal Rule 32 for other legal purposes. SPECIAL TERMS REGARDING REVOCABILITY OF CRIMINAL JUSTICE PROGRAM RELEASES: Although HIPAA requires that consents be revocable and does not have an exception when a patient is mandated into treatment through the criminal justice system (CJS), 42 C.F.R. Part 2 sets forth some special rules when a patient’s participation in a treatment program is an official condition of probation or parole, sentence, dismissal of charges, release from imprisonment, or other disposition of any criminal proceeding. While a consent form (or court order) is still required before any disclosure can be made about a CJS referral, the rules concerning duration and revocability of the consent are different. Under special rules of 42 C.F.R. Part 2, consent can be made irrevocable until a certain specified date or condition occurs, and the duration of the consent can be linked to the final disposition of the criminal proceeding. 42 C.F.R. §2.35. This allows programs to provide information even after the client leaves treatment. If the client does not comply with treatment, the program can report the problem to the judge or prosecuting attorney to testify in a probation revocation hearing because there has been no final disposition of the criminal matter. A CJS consent allows programs to use the expiration condition provided in 42 C.F.R. Part 2 “when there is a substantial change in the patient’s criminal justice status.” A substantial change in status occurs whenever the patient moves from one phase of the CJS to the next. For example, if a client were on parole or probation, there would be a change in the CJS status when the parole or probation ends, either by successful completion or revocation. Thus the program could provide periodic reports to the parole or probation officer monitoring the client, and could even testify at a parole or probation revocation hearing, since no change in criminal status would occur until after the hearing. 3.Expiration and Release of Liability I release and forever hold harmless the State of Idaho, IDOC, and their agents and employees from and against all claims, damages, or liability resulting from any action pursuant to this request. _____________________________________________ ___________________________ Signature of Person Requesting Release of Records Date _____________________________________________ _____________________________________ ____________ Name of Witness (or Parent/Guardian where required) Signature of Witness/Parent/Guardian Date Note to Releasor: IDOC is not funded to provide payment for your services or copying fees. Any expense or fee involved in this request should be billed to your client and not to IDOC.