Attachment J-4 Release of Information-Health Records.pdf
PDF 102 KB Posted
- Attached to
- Residential Drug Treatment Services
- Solicitation number
- 9594CS26Q0055
About this file
This is a health records release form template used by the Court Services and Offender Supervision Agency (CSOSA) for the District of Columbia to authorize disclosure of offender health information.
The form permits offenders to consent to the release of their health records to specified authorized recipients for stated purposes. Key fields include the offender's name, the nature of information to be disclosed, the authorized recipient(s), and the purpose of disclosure. The form explicitly prohibits redisclosure of released information without the offender's authorization and includes specific protections for HIV/AIDS and cancer information under District of Columbia Official Code §§ 7-302 and 7-1605, requiring express written consent for any redisclosure of such sensitive health data. The offender must provide identification information including date of birth, DCDC number, and PDID number. The consent may be revoked in writing at any time and will expire on a date specified by the offender. A witness signature and date are required. The form notes that this template cannot be used to authorize disclosure of mental health information, which requires a separate form complying with the D.C. Mental Health Information Act.
View the file
Other files
Show all 21
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
Court Services and Offender Supervision Agency for the District of Columbia
CSOSA - Health Revised 8/2008
Attachment J-4: 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.
| txt_001: |
| txt_002: |
| txt_003: |
| txt_004: |
| txt_005: |
| txt_006: |
| txt_007: |
| txt_008: |
| txt_009: |
| txt_010: |
| txt_011: |
| btn_print: |
| btn_reset: |
File details come from the government source that posted it. Updated .