Rev. 3/00 consent for disclosure of medical and non-medical records from alcoholism and drug abuse treatment programs

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REV. 3/00


Federal law and regulations protect the confidentiality of alcohol and drug abuse treatment records. In general, the program you are at now or went to in the past may not tell anyone outside that program about your treatment, or disclose any information identifying you as an alcohol or drug abuser unless you consent to that disclosure in writing.

Sign AFTER you read and understand the consent you are giving.

You may ask questions about anything you do not understand.

I, __________________________________________________________________ authorize and request

(Client Name)
__________________________________________________________________________ to disclose:

(Name of the Program which is to make the disclosure)

Factors related to my Treatment/Employability/Disability:
1. Initial Evaluation.

2. Diagnoses and Prognoses.

3. Date of admission or referral to an alternative treatment program.

4. Assessment results and history including evaluation of psycho-social and vocational functioning.

5. Summary of treatment plan, progress and compliance.

6. Attendance

7. Date of discharge and discharge status.

8. Discharge plan.

9. Employment-related information.

10. Educational and training related information.

11. Other: ______________________________________________________________________

I authorize the release of the information specified above too the local county department of social services and/or its designee, and the New York State Department of Social Services, for communication and disclosure to one another, so that my eligibility or continued eligibility for public assistance and medical assistance benefits and my readiness/ability to participate in a Work Experience Program can be determined. If I am required to apply for benefits administered by the Social Security Administration, the information specified above may be shared with the Social Security Administration.

I understand that, except for action already taken, I can rescind this consent at any time. If I do not take back this consent, it will end upon: Discontinuance of Public Assistance Benefits.

X_______________________________________________________________ ______________________________

(Signature of Client) (Date Signed)

________________________________________________________________ ______________________________

(Signature of Parent, guardian of person authorized to sign in lieu of client, where required) (Date Signed)

________________________________________________________________ ______________________________

(Contact Person/County) (Date Signed)

________________________________________________________________ ______________________________

(Signature for Withdrawals by Client) (Date Signed)


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