Attachment J-2 CSOSA Consent Release of Sensitive Information-Mental Health or Sex Offender.pdf
PDF 260 KB Posted
- Attached to
- Outpatient Treatment Services
- Solicitation number
- 9594CS26Q0003
About this file
This is a consent form template issued by the Court Services and Offender Supervision Agency (CSOSA) for the District of Columbia that authorizes the release of sensitive offender information related to mental health treatment or sex offender treatment.
The form permits an offender to consent to CSOSA disclosing specified mental health or sex offender treatment information to authorized recipients for stated purposes. Key terms include: the authorization is valid for up to 365 calendar days from the date of signature unless an earlier expiration date is specified; CSOSA may release information obtained after the authorization date during this period; the recipient organization cannot further disclose the information without additional offender authorization; and the offender retains the right to revoke the consent in writing except in connection with life or health insurance policies under D.C. Official Code § 7-1202.02(a)(3). The form includes required fields for the offender's name, date of birth, DCDC number, and PDID number, along with signature blocks for both the offender and a witness. Copies of the executed form must be provided to the offender, the individual responsible for disclosure, and placed in the offender's file. The form references the District of Columbia Mental Health Information Act of 1978 and notes that unauthorized disclosure violations carry civil and criminal penalties.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
COMMUNITY SUPERVISION SERVICES
ATTACHMENT J-2: CONSENT FOR THE RELEASE OF SENSITIVE OFFENDER
INFORMATION: MENTAL HEALTH TREATMENT OR SEX OFFENDER TREATMENT
I, ___________________________________________, hereby consent to the release of the following information, (Name of offender)
(nature of information to be disclosed) by the Court Services and Offender Supervision Agency (CSOSA) to _______________________________________.
(authorized person or organization recipient)
In authorizing this disclosure of mental health information, I understand that the information will be used for the purpose of
_______________________________________________ , both now and in the future. I understand that I may permit
CSOSA to release information that it obtains after the date of this authorization for a period of up to 365 calendar days. If I do not state below when this authorization expires, then it will expire 365 calendar days from the date that I signed this form. I understand that this information cannot be disclosed by the person or organization who receives it without my authorization and that the law requires this notice:
The unauthorized disclosure of mental health information violates the provisions of the District of Columbia Mental Health Information Act of 1978 (D.C. Official Code §§ 7-1201.01 – 7-1208.07). Disclosures may only be made pursuant to a valid authorization by the client or as provided in Titles III or IV that Act.
The Act provides for civil damages and criminal penalties for violations.
I understand that this consent may be revoked in writing by me except in connection with a life or health insurance policy under D.C. Official Code § 7-1202.02(a)(3). I also understand that I have a right to examine and review my mental health records. I understand that a copy of this waiver will be provided to me as well as the individual responsible for making the actual disclosure(s). I also understand that a copy of this waiver will be placed in my file.
Authorization for release of information expires on __________(date cannot exceed 365 calendar days from the date this form is signed).
Signature of Offender/Date Signed Witnessed By/Date Signed
Offender’s Date of Birth
Offender’s DCDC Number
Offender’s PDID Number
[CSOSA - MH/S.O.]
| txt_name01: |
| txt_purpose01: |
| txt_date01: |
| txt_birthdate01: |
| txt_recipient01: |
| txt_dcdcnumb: |
| txt_pdidnumb: |
| btn_print: |
| btn_save: |
| btn_reset: |
| txt_info01: |
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