Attachment J-5 Release of Information-Privacy Act Waiver.pdf
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- Attached to
- Residential Drug Treatment Services (FY 2024)
- Solicitation number
- 9594CS24R0022
About this file
This document contains details for a federal contract solicitation seeking residential drug treatment services. The Court Services and Offender Supervision Agency is soliciting proposals to stabilize substance use disorders, enhance supervision compliance, and promote recovery for offenders in Washington D.C., Maryland, and Virginia. Services will include substance use disorder treatment at a contractor's facility within a 30-mile radius of 633 Indiana Avenue NW in Washington D.C. Placements will normally be up to 30 days including a 30-day restricted movement period but may be extended based on recommendations involving the offender's Community Supervision Officer. Contractors must coordinate access to community recovery systems and continuity of care after program completion to return offenders to their communities free from illicit substance use.
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Court Services and Offender Supervision Agency for the District of Columbia
CSOSA-OGC-0005 Revision: August 2008
Attachment J-5: RELEASE OF INFORMATION
PRIVACY ACT WAIVER
I, ________________________________________________ [Name], hereby authorize and give my prior written consent pursuant to 5 U.S.C. § 552a(b) to the
Court Services and Offender Supervision Agency for the District of Columbia, to disclose the information noted below concerning me to the recipient(s) noted below for the purpose noted below.
Information to be disclosed:
Recipient(s):
Purpose of disclosure:
I declare under penalty of perjury that the foregoing is true and correct.
Executed this ______ day of ______________, 202_.
Signature
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