Attachment J-3 Release of Information and Waiver General Third Party Disclosure.docx
DOCX document 62 KB Posted
- Attached to
- Residential Drug Treatment Services
- Solicitation number
- 9594CS26Q0055
About this file
This is a template form for authorization of information disclosure used by the Court Services and Offender Supervision Agency for the District of Columbia (CSOSA). The form enables offenders under supervision to consent to the sharing of their personal information with third parties for coordinated treatment services purposes. The form allows offenders to specify which categories of information may be disclosed, including substance abuse treatment results (drug test results), medical records (PPD/TST, X-ray results), and mental health or sex offender information along with medication and medical condition details. The disclosure authorization remains effective until the offender revokes it or until a date specified by the offender, and any redisclosure of information is prohibited without the offender's express written authorization. The form requires signature and witness attestation along with the offender's identifying information including date of birth, DCDC number, and PDID number.
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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 .