Attachment J-3 Release of Information-Health Records.pdf

Court Services and Offender Supervision Agency for the District of Columbia

CSOSA - Health Revised 8/2008

Attachment J-3: RELEASE OF INFORMATION:

Health Records*

I, __________________________________________________________(Name of offender), hereby consent to the release of the information noted in the table below by _________________ to the authorized person(s) or organization recipient(s) noted in the table below.

In authorizing this disclosure of health information, I understand that the information will be used for the purpose noted in the table below, both now and for as long as my consent remains valid.

Nature of Information to be Disclosed:

Authorized Recipient (Person or Organization):

Purpose of Disclosure:

I understand that this information cannot be redisclosed by the person or organization who receives it without my authorization.

The unauthorized disclosure of HIV/AIDS or cancer information violates the provisions of the District of Columbia Official Code §§ 7-302 and 7-1605, which provide for the confidentiality of HIV/AIDS and cancer patient records. Any HIV/AIDS or cancer information may not be redisclosed by the recipient without my express written consent.

I understand that this consent may be revoked in writing by me at any time, and if not revoked, will expire on _________. I also understand that a copy of this waiver will be placed in my file.

Signature of Offender:

Date Signed:

Offender’s Date of Birth:

Offender’s DCDC Number:

Offender’s PDID Number:

Witnessed by:

Date Signed:

* Note that this form may NOT be used to authorize the disclosure of mental health information. The D.C. Mental Health Information Act requires the use of specific language to authorize the disclosure of such information. See the mental health consent form.