TE3_-_Attch_4._DA_Form_5018_v._Mar_2019.pdf

SIGNATURE OF CLIENT DATE

NAME OF WITNESS (Type or print) SIGNATURE DATE

NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE (Type or print) DATE

SIGNATURE

ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION

For use of this form, see AR 600-85; the proponent agency is DCS, G-1.

criminal justice system status changes to

1.

SECTION A - CONSENT

I, do hereby voluntarily consent to the release of the following information by pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to

, this day of , (client's full name)

(name of installation ADAPCP) for the purpose of namely, (extent or nature of information to be disclosed)

SECTION B - EXPIRATION/REVOCATION

(Check applicable paragraph)

- Or - (For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85)

2. I understand that this consent automatically expires 60 days from today's date or when my present

SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION

In my judgment, the release of an evaluation of the present or past status of (client's name) in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.

DA FORM 5018-R, NOV 1981 APD LC v3.00ES

NOTE:

I understand that this consent automatically expires when the above disclosure action has been taken in

Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program Physician or the Clinical Director.

Further, I understand that if my release from confinement, probation, or parole is conditioned upon my participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement, probation, or parole.

reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at any time.

SIGNATURE OF CLIENT

DATE

NAME OF WITNESS (

Type or print)

SIGNATURE

DATE

NAME OF MEDCEN/MEDDAC COMMANDER OR DESIGNATED REPRESENTATIVE

(Type or print)

DATE

SIGNATURE

ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION

For use of this form, see AR 600-85; the proponent agency is DCS, G-1.

criminal justice system status changes to 1.

SECTION A - CONSENT

I, do hereby voluntarily consent to the release of the following information by pertaining to my identity, diagnosis, prognosis, or treatment from any Army record maintained in connection with alcohol or other drug abuse education, training, treatment, rehabilitatiton, or research to , this day of (client's full name) (name of installation ADAPCP) for the purpose of namely, (extent or nature of information to be disclosed)

SECTION B - EXPIRATION/REVOCATION

(Check applicable paragraph)

- Or - (For disclosure to civilian criminal justice officials under the provisions of paragraphs 6-9b(4)(b) and 6-10e(3), AR 600-85) 2.

I understand that this consent automatically expires 60 days from today's date or when my present

SECTION C - APPROVAL AUTHORITY FOR RELEASE OF INFORMATION

In my judgment, the release of an evaluation of the present or past status of (client's name) in the alcohol or other drug treatment and rehabilitation program will not be harmful to him/her.

DA FORM 5018-R, NOV 1981

APD LC v3.00ES

NOTE:

I understand that this consent automatically expires when the above disclosure action has been taken in Other than the MEDCEN/MEDDAC Commander, approval authority for release of information may be delegated to the Program Physician or the Clinical Director.

Further, I understand that if my release from confinement, probation, or parole is conditioned upon my participation in the ADAPCP, I cannot revoke this consent until there has been a formal and effective termination or revocation of my release from such confinement, probation, or parole.

reliance thereon and that, except to the extent that such action has been taken, I can revoke this consent at any time.

3.00

DA FORM 5018-R, NOV 1981

ADAPCP CLIENT'S CONSENT STATEMENT FOR RELEASE OF TREATMENT INFORMATION

APD