Attachment J-3 Relase of Information and Waiver General Third Party Disclosure.docx
DOCX document 62 KB Posted
- Attached to
- Supportive Housing Services (Up to 180 Days)
- Solicitation number
- 9594CS26Q0075
About this file
This is a Release of Information and Waiver for General Third Party Disclosure form used in conjunction with the Court Services and Offender Supervision Agency (CSOSA) Supportive Housing Services solicitation (9594CS26Q0075). The document serves as a template for obtaining participant consent to share personal information with third parties in connection with housing services provision.
The form authorizes CSOSA and contracted service providers to disclose participant information to relevant third parties as necessary for program administration and service delivery. It requires participant signature and acknowledgment that they understand the scope of information sharing. The waiver covers disclosure to government agencies, housing providers, healthcare professionals, and other entities involved in delivering supportive housing services. This form is a standard administrative requirement for contractors providing housing services to CSOSA clients and must be completed and maintained as part of participant case files during the contract performance period.
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Text version
Attachment J-3
Court Services and Offender Supervision Agency for the District of Columbia
COMMUNITY SUPERVISION SERVICES
AUTHORIZATION FOR RELEASE OF INFORMATION AND WAIVER: GENERAL THIRD PARTY DISCLOSURE
[THIRD PARTY GENERAL]
I, , hereby consent to the disclosure of information (Name of Offender) specified below between the Court Services and Offender Supervision Agency for the District of Columbia and
(Name of Third Party)
The purpose of and need for the disclosure is to inform the party named above of coordinate treatment services (Purpose of Disclosure)
The information to be disclosed is limited to the following:
Substance Abuse Treatment (authorizes sharing of CSOSA drug test results), Medical Records (PPD/TST, X-Ray results), Mental Health/Sex Offender Information, medications and medical conditions (diagnoses and recommendations)
(Information to be Disclosed)
I understand that this consent will remain effective until it is revoked by me, or until .
(Enter Date)
I also understand that a redisclosure of this information may not be made without my express written authorization.
Signature of Offender/ Date Signed Witnessed By/Date Signed Offender’s Date of Birth
Offender’s DCDC Number
Offender’s PDID Number Print Form Reset Form image1.png
File details come from the government source that posted it. Updated .