Attachment J-5 Release of Mental Health-Sex Offender Information.pdf
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- Solicitation number
- 9594CS26Q0004
About this file
This is a consent form template used by the Court Services and Offender Supervision Agency (CSOSA) for the District of Columbia to authorize the release of sensitive offender information related to mental health treatment or sex offender treatment. The form serves as a standardized document for offenders to grant permission for CSOSA to disclose their protected health information to authorized recipients.
The form requires the offender to identify themselves, specify the nature of information to be disclosed, designate the authorized recipient organization, and state the intended purpose of the disclosure. The authorization permits CSOSA to release information obtained after the form's signature date for up to 365 calendar days, with the expiration date specified by the offender or defaulting to 365 days from the signing date. The form includes mandatory statutory notice regarding the District of Columbia Mental Health Information Act of 1978, which prohibits unauthorized disclosure and provides civil and criminal penalties for violations. The offender must acknowledge their right to revoke consent in writing (except for life or health insurance matters), their right to examine mental health records, and that copies will be provided to the offender, the disclosing official, and placed in the offender's file. The form requires signature by the offender and a witness, along with the offender's date of birth, DCDC number, and PDID number for identification purposes.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
COMMUNITY SUPERVISION SERVICES
CONSENT FOR THE RELEASE OF SENSITIVE OFFENDER INFORMATION:
MENTAL HEALTH TREATMENT
OR
SEX OFFENDER TREATMENT
I, ___________________________________________, hereby consent to the release of the following information, (Name of offender)
(nature of information to be disclosed) by the Court Services and Offender Supervision Agency (CSOSA) to _______________________________________.
(authorized person or organization recipient)
In authorizing this disclosure of mental health information, I understand that the information will be used for the purpose of
_______________________________________________ , both now and in the future. I understand that I may permit
CSOSA to release information that it obtains after the date of this authorization for a period of up to 365 calendar days. If I do not state below when this authorization expires, then it will expire 365 calendar days from the date that I signed this form. I understand that this information cannot be disclosed by the person or organization who receives it without my authorization and that the law requires this notice:
The unauthorized disclosure of mental health information violates the provisions of the District of Columbia Mental Health Information Act of 1978 (D.C. Official Code §§ 7-1201.01 – 7-1208.07). Disclosures may only be made pursuant to a valid authorization by the client or as provided in Titles III or IV that Act.
The Act provides for civil damages and criminal penalties for violations.
I understand that this consent may be revoked in writing by me except in connection with a life or health insurance policy under D.C. Official Code § 7-1202.02(a)(3). I also understand that I have a right to examine and review my mental health records. I understand that a copy of this waiver will be provided to me as well as the individual responsible for making the actual disclosure(s). I also understand that a copy of this waiver will be placed in my file.
Authorization for release of information expires on __________(date cannot exceed 365 calendar days from the date this form is signed).
Signature of Offender/Date Signed Witnessed By/Date Signed
Offender’s Date of Birth
Offender’s DCDC Number
Offender’s PDID Number
[CSOSA - MH/S.O.]
Attachment J-5
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