Attachment J-4 Release of Information - Health Records.pdf
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- Solicitation number
- 9594CS26Q0004
About this file
This is a health records release of information form issued by the Court Services and Offender Supervision Agency (CSOSA) for the District of Columbia, revised August 2008.
The form serves as a consent document that permits offenders under CSOSA supervision to authorize the disclosure of their health records to specified recipients for designated purposes. The form requires the offender to identify the nature of information to be disclosed, the authorized recipient (person or organization), and the purpose of the disclosure. Key provisions include a prohibition on redisclosure without the offender's written authorization, specific protections for HIV/AIDS and cancer information under District of Columbia Official Code §§ 7-302 and 7-1605, the ability to revoke consent in writing at any time, and an expiration date for the consent. The form requires completion of offender identification information including name, date of birth, DCDC number, and PDID number, along with signature, date, and witness information. A critical limitation notes that this form cannot be used to authorize disclosure of mental health information, which requires a separate mental health consent form compliant with the D.C. Mental Health Information Act.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
CSOSA - Health Revised 8/2008
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.
Attachment J-4
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