Attachment J-6 Authorization for Release of Information_Waiver-General Third Party Disclosure.pdf
PDF 259 KB Posted
- Attached to
- Outpatient Treatment Services Federal contract opportunity
- Solicitation number
- 9594CS26Q0003
About this file
This is a form template for the Court Services and Offender Supervision Agency for the District of Columbia that authorizes the release of offender information to third parties. The form allows an offender to provide written consent for the disclosure of specified information between the Agency and a named third party. The offender must identify the purpose and need for the disclosure, specify what information may be shared, and designate an expiration date for the consent or indicate that it remains effective until revoked. The form includes fields for the offender's signature, date signed, witness signature and date, date of birth, DCDC number, and PDID number. The form explicitly states that any redisclosure of the released information requires the offender's express written authorization and cannot occur without it. The template includes Print Form and Reset Form buttons for administrative use.
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Text version
Court Services and Offender Supervision Agency for the District of Columbia
COMMUNITY SUPERVISION SERVICES
AUTHORIZATION FOR RELEASE OF INFORMATION AND WAIVER:
GENERAL THIRD PARTY DISCLOSURE
[THIRD PARTY GENERAL]
I, ___________________________________________, hereby consent to the disclosure of information (Name of Offender) specified below between the Court Services and Offender Supervision Agency for the District of Columbia and
(Name of Third Party)
The purpose of and need for the disclosure is to inform the party named above of
(Purpose of Disclosure)
The information to be disclosed is limited to the following
(Information to be Disclosed)
I understand that this consent will remain effective until it is revoked by me, or until ______________________.
(Enter Date)
I also understand that a redisclosure of this information may not be made without my express written authorization.
Signature of Offender/ Date Signed Witnessed By/Date Signed
Offender’s Date of Birth
Offender’s DCDC Number
Offender’s PDID Number
Attachment J-6
| txt_name_off: |
| txt_purpose: |
| txt_info: |
| txt_thirdparty: |
| txt_date01: |
| txt_birthdate: |
| txt_dcdc: |
| txt_pdid: |
| btn_print: |
| btn_reset: |
File details come from the government source that posted it. Updated .